A nurse is performing a focused eye assessment. Select up to 5 unexpected findings.
Consensual constriction present
Snellen chart finding 20/40
sting to the upper eyelid
Pupil size 4 mm
Jerky eye movements with the 6 Cardinal Fields of Gaze
Pupil size 6 mm
Erythema to lower eyelid
Correct Answer : C,E,G
A) Consensual constriction present: Consensual constriction of the pupil is a normal finding when light is shined into one eye, causing both pupils to constrict simultaneously. This is a normal response and not an unexpected finding.
B) Snellen chart finding 20/40: A Snellen chart result of 20/40 indicates that the patient's vision is slightly less than normal but still within acceptable limits for daily functioning. This is not considered an unexpected or abnormal finding for an adult.
C) Sting to the upper eyelid: A sting or discomfort in the upper eyelid is an unexpected finding and may suggest irritation, infection (such as blepharitis), or trauma. This symptom should be further evaluated, as it is not typical during a normal eye assessment.
D) Pupil size 4 mm: A pupil size of 4 mm is considered normal and expected in a well-lit environment for most adults. It falls within the typical range for pupil size, so it is not an unexpected finding.
E) Jerky eye movements with the 6 Cardinal Fields of Gaze: Jerky or abnormal eye movements, such as nystagmus or inability to follow the cardinal fields of gaze smoothly, are unexpected findings. This could suggest neurological conditions, muscle weakness, or issues with the vestibular system, all of which warrant further investigation.
F) Pupil size 6 mm: A pupil size of 6 mm can be normal in low-light conditions (dilated pupils), but in a well-lit environment, it is on the larger end of the normal range. If this is observed in normal light, it may indicate a pathological condition, medication side effect, or neurological issue, but it could also be normal for some individuals. It’s less of an "unexpected" finding than jerky eye movements or a stinging sensation, but it may warrant monitoring if unusual for the patient.
G) Erythema to lower eyelid: Erythema (redness) to the lower eyelid is an unexpected finding, which could suggest an infection (such as conjunctivitis), irritation, or inflammation. This finding should be further assessed, as redness in the eyelid area is not typical during a normal eye assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Allergic conjunctivitis: Allergic conjunctivitis typically presents with symptoms such as itching, redness, and watery discharge, but the discharge is usually clear, not thick and sticky. It is caused by an allergic reaction and usually does not involve the white, thick, sticky drainage that is described in the question. Itching is a hallmark symptom, but it doesn't typically cause thick drainage.
B) Cataracts: Cataracts involve clouding of the eye’s lens, leading to blurry vision or difficulty seeing, but they do not cause redness, itching, or thick sticky drainage in the conjunctiva sac. Cataracts are a lens problem, not an issue with the conjunctiva, and would not present with the symptoms described in the question.
C) Bacterial conjunctivitis: Bacterial conjunctivitis is characterized by redness, thick, white or yellowish sticky discharge, and often causes itching or discomfort. The discharge is typically thick and can cause the eyelids to stick together, especially upon waking. This condition matches the symptoms described and is a common eye infection caused by bacteria like Staphylococcus aureus or Streptococcus pneumoniae.
D) Viral conjunctivitis: Viral conjunctivitis also causes redness and watery discharge, but the discharge tends to be thin and watery, not thick and sticky like bacterial conjunctivitis. Viral conjunctivitis often involves symptoms like tearing, irritation, and a more watery, clear discharge, and is typically associated with upper respiratory symptoms. It does not match the description of thick, white, sticky drainage.
Correct Answer is ["B","C"]
Explanation
A) Acromegaly: Acromegaly is a condition caused by excess growth hormone, leading to enlargement of bones and tissues, particularly in the hands, feet, and face. While facial features can appear more pronounced due to bone growth, acromegaly itself does not cause facial drooping as a prominent symptom. The condition does not typically present with the sudden onset of facial weakness or asymmetry associated with drooping.
B) Bell’s Palsy: Bell’s Palsy is a disorder that affects the facial nerve, leading to sudden, unilateral facial drooping or paralysis. It is often caused by inflammation of the facial nerve, and facial drooping is one of its hallmark symptoms. It usually occurs on one side of the face, causing weakness or loss of muscle tone, leading to the drooping appearance.
C) CVA (Cerebrovascular Accident): A CVA, or stroke, can result in facial drooping, typically on one side of the face, if the stroke affects areas of the brain controlling facial muscles. A common sign of a stroke is the sudden development of facial asymmetry, including drooping of the mouth or eyelid. It is an important symptom to monitor in assessing neurological function following a stroke.
D) Parkinson’s Disease: Parkinson’s disease can cause facial changes, such as reduced blinking and a "masked" appearance, but it does not typically cause facial drooping in the same way that Bell's Palsy or a CVA would. Parkinson’s-related facial changes stem from reduced movement rather than sudden weakness or paralysis of the facial muscles. While facial expression can be diminished, true drooping is less common.
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