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 D

Explanation

A. The eyes converge to focus on the light.

This statement refers to the convergence reflex, where both eyes move medially (towards each other) to maintain single binocular vision when focusing on a near object. It is not related to the pupillary light reflex, which involves changes in pupil size in response to light.

B. The eye focuses the image in the center of the pupil.

This choice does not accurately describe the pupillary light reflex. The pupillary light reflex involves constriction of the pupil in response to light, not focusing an image in the center of the pupil.

C. Dilation of both pupils occurs in response to bright light.

This statement is incorrect. In response to bright light, the pupils should constrict, not dilate. Dilation of pupils in bright light could indicate an abnormal response, such as in cases of certain neurological conditions or drug use.

D. Constriction of both pupils occurs in response to bright light.

This choice is correct. In the pupillary light reflex, both pupils constrict when exposed to bright light. This response is a protective mechanism to prevent excessive light from entering the eyes, ensuring optimal visual acuity.

A. The third heart sound (S3) B. A friction rub C. The fourth heart sound (S4) D. A split second heart sound S2

Correct Answer is A

Explanation

A. The third heart sound (S3):

The third heart sound (S3) is an abnormal heart sound that occurs during early diastole, immediately after S2 (the second heart sound). It is caused by the rapid filling of the ventricles and is often associated with conditions like heart failure. In heart failure, the ventricles become stiff, causing vibrations that produce the S3 sound.

B. A friction rub:

A friction rub is a high-pitched, scratchy sound heard during both systole and diastole. It is caused by the rubbing together of inflamed pericardial layers (pericarditis) and is usually heard best at the left lower sternal border. Friction rubs can indicate pericardial inflammation and are often heard in conditions such as pericarditis or after a myocardial infarction.

C. The fourth heart sound (S4):

The fourth heart sound (S4) occurs late in diastole, just before S1, and is caused by atrial contraction. It is associated with increased resistance to ventricular filling, often due to conditions like hypertension or aortic stenosis. The S4 sound is heard as a low-pitched "atrial gallop."

D. A split second heart sound S2:

The second heart sound (S2) represents the closure of the aortic and pulmonic valves. Normally, S2 has two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). A split S2 occurs when A2 and P2 do not close simultaneously. A physiological split S2 is common during inspiration and occurs due to delayed closure of the pulmonic valve. An abnormal or fixed split S2 can indicate underlying heart conditions such as atrial septal defect (ASD) or right bundle branch block (RBBB).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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