A client is concerned about their 3-year-old child's vision. What technique should the nurse use to assess the child's visual acuity?
Perform the Snellen eye chart test.
Ask the child to identify colors.
Use an ophthalmoscope to examine the eyes.
Observe the child's eye movements.
The Correct Answer is A
A. Correct. Using the Snellen eye chart is a standard method for assessing visual acuity in children who can cooperate with the test.
B. Incorrect. Asking the child to identify colors is not a specific test for visual acuity.
C. Incorrect. Using an ophthalmoscope is a tool for examining the internal structures of the eye, not for assessing visual acuity.
D. Incorrect. Observing eye movements is important for assessing coordination and alignment of the eyes but does not directly measure visual acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Depressed and sunken fontanelles are signs of dehydration and should be evaluated promptly.
B. Incorrect. Flat and firm fontanelles may indicate normal hydration, but slight bulging is considered normal in infants.
C. Correct. Slightly bulging fontanelles can be normal in infants due to crying, coughing, or changes in intracranial pressure. However, severely bulging or depressed fontanelles are concerning and require further evaluation.
D. Incorrect. Pulsating fontanelles are a normal finding and are related to the pulsations of blood flow in the area.
Correct Answer is B
Explanation
A. Incorrect. The Babinski reflex, where the big toe extends and the other toes fan out, is normal in infants but typically disappears by the age of 2.
B. Correct. The Moro reflex is a normal startle response in newborns. It involves symmetrically spreading the arms and then bringing them back to the body when the infant experiences a sudden change in position or stimulation.
C. Incorrect. The tonic neck reflex, also known as the "fencing" reflex, is a normal infantile reflex but typically disappears by 6 months.
D. Incorrect. The plantar grasp reflex, where the toes curl in when the sole of the foot is touched, is normal in infants but typically disappears by 9 months.
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