A nurse is caring for a patient diagnosed with cataracts. What cue is consistent with this diagnosis during the inspection of the eyes?
pupil constriction
cloudiness in the iris
redness in the sclera
cloudiness in the lens
The Correct Answer is D
A) Pupil constriction: Pupil constriction (miosis) is not a typical sign of cataracts. Cataracts usually cause blurred or cloudy vision due to the clouding of the lens. Pupil constriction may occur in other conditions, such as in response to certain medications or neurological changes, but it is not associated with cataracts.
B) Cloudiness in the iris: The iris is the colored part of the eye that controls the size of the pupil. While cataracts affect vision, they typically involve the lens rather than the iris. Cloudiness in the iris could indicate other conditions, such as inflammation or infection, but it is not a characteristic of cataracts.
C) Redness in the sclera: Redness in the sclera (the white part of the eye) is usually caused by irritation, infection, or injury, such as conjunctivitis or subconjunctival hemorrhage. It is not a typical sign of cataracts, which primarily affect the lens and do not typically cause changes to the sclera.
D) Cloudiness in the lens: Cataracts are characterized by the clouding of the lens, which can result in blurry, hazy, or diminished vision. This cloudiness is visible during an eye examination, typically as a white or grayish opacity in the lens. This is the most consistent finding with cataracts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Trachea is midline: Palpating the neck using a three-finger technique is not typically used to assess the position of the trachea. The trachea's position is assessed by placing one finger on each side of the trachea and gently palpating to check for any deviation from the midline. This technique is different from using three fingers to assess the thyroid.
B) Location of the thyroid: The three-finger technique is often used by nurses to palpate the thyroid gland. This method helps assess the size, shape, and consistency of the thyroid as well as to check for any enlargement (goiter) or tenderness. The technique is used to help guide the nurse’s fingers to the correct area for palpating the thyroid gland, typically located just below the Adam’s apple in the neck.
C) Location of lymph nodes: The location of lymph nodes is assessed by palpating different areas of the neck using the pads of the fingers or a gentle circular motion. The three-finger technique is not typically used to assess lymph nodes. Instead, lymph nodes are individually palpated with one or two fingers to feel for enlargement or tenderness.
D) Ability for client to swallow: Swallowing ability is assessed by observing the patient while they swallow fluids or food and by asking about any difficulty with swallowing (dysphagia). The three-finger technique does not assess swallowing directly; it is a method used for palpating structures in the neck like the thyroid.
Correct Answer is B
Explanation
A) Expected finding: Cotton wool spots are not considered an expected finding during a routine eye exam. These spots are indicative of underlying pathology, and their presence typically suggests an abnormality that warrants further investigation. They are not part of normal eye anatomy or typical health.
B) Unexpected finding: Cotton wool spots are small, white, fluffy lesions in the retina that occur due to microinfarctions of retinal nerve fibers. Their presence is considered an unexpected or abnormal finding during an ophthalmoscopic exam and can be associated with several conditions, including diabetes, hypertension, and other systemic diseases that affect blood flow to the retina. Their appearance is a signal of potential underlying health issues that require attention.
C) Expected variation: Cotton wool spots are not a variation of normal anatomy or function. They are pathological and should not be regarded as a normal variation of retinal appearance during an eye exam.
D) Irrelevant: The term "irrelevant" is not applicable in this context, as the presence of cotton wool spots is highly relevant to the clinical assessment. Their discovery suggests a need for further investigation into the patient's overall health, particularly cardiovascular or systemic conditions.
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