When screening a 5-year-old for strabismus, which action should the nurse take?

Observe the child for blank, sunken eyes.

Inspect the child for the setting-sun sign.

Have the child identify colored patterns on polychromatic cards.

Direct the child through the six cardinal positions of gaze.

Answer and Explanation

The Correct Answer is D

A. Observe the child for blank, sunken eyes. Blank, sunken eyes are not associated with strabismus. These could be signs of other conditions, such as dehydration or severe malnutrition, but they are not relevant for assessing strabismus.

B. Inspect the child for the setting-sun sign. The setting-sun sign is more commonly associated with increased intracranial pressure in infants and is not a relevant observation for detecting strabismus in a 5-year-old child.

C. Have the child identify colored patterns on polychromatic cards. Identifying colored patterns on polychromatic cards is a test for color vision, not for strabismus. Strabismus involves misalignment of the eyes rather than a problem with color perception.

D. Direct the child through the six cardinal positions of gaze. The six cardinal positions of gaze test the alignment and movement of the eyes. The nurse asks the child to follow an object with their eyes as it is moved through these six positions. Any inability of the eyes to maintain proper alignment or any deviation from the expected movement can indicate strabismus. This is an effective and commonly used method to screen for strabismus in children.

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Correct Answer is B

No explanation

A. Close blinds room so is darkened. B. Ask the mother to release the child. C. Monitor the child's airway and tongue. D. Administer an anticonvulsant medication. E. Place pillows inside the side rails.

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

Explanation

A. Closing the blinds room so is darkened is inappropriate. The lighting in the room is unlikely to have an impact on the seizure or its management. Ensuring safety and maintaining the airway is the priority.

B.Asking the mother to release the child is appropriate. It’s important to ensure the safety of both the child and the mother. The mother should be asked to release the child to prevent any potential harm to the child during the seizure

C. Monitoring the child's airway and tongue is appropriate. During a seizure, there is a risk of the child's airway being compromised. The nurse should closely monitor the child's airway to ensure that it remains open and that the tongue does not obstruct the airway. Positioning the child on their side can also help prevent choking.

D. Administering an anticonvulsant medication is inappropriate. The nurse should not administer medication without a healthcare provider's order. In a seizure emergency, the focus is on maintaining safety and managing the seizure itself.

E. Place pillows inside the side rails: This is a correct action to prevent injury during the seizure. Padding the side rails helps protect the child from hitting their head or limbs on the hard surfaces.

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When screening a 5-year-old for strabismus, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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