A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?
The infant's eyes turn toward the light.
The infant's head turns away from the light.
The infant's eyes remain focused toward the floor.
The infant closes their eyes.
The Correct Answer is A
A.
A. The infant's eyes turn toward the light - This is the expected finding known as the "fixation reflex," where infants naturally turn their eyes toward a light source.
B. The infant's head turns away from the light - This would not be an expected finding during a vision screening; it may suggest a different reflex or issue.
C. The infant's eyes remain focused toward the floor - This would not be an expected finding during a vision screening; it may suggest a different visual or developmental concern.
D. The infant closes their eyes - Closing the eyes in response to light is not the typical response during a vision screening for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.
B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.
C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.
D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.
Correct Answer is A
Explanation
- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.
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