A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Lid lag when moving the eyes from a superior to an inferior position

Nystagmus when reading the Snellen chart

Parallel movement of both eyes

Convergence of the eyes

Answer and Explanation

The Correct Answer is C

A) Lid lag when moving the eyes from a superior to an inferior position:
This is incorrect. Lid lag refers to a delay in the movement of the eyelid as the eyes move downward. It is considered an abnormal finding and is often associated with conditions like hyperthyroidism (Graves' disease), where the eyelid does not follow the downward gaze appropriately. In the diagnostic positions test, normal eye movement should not include lid lag.

B) Nystagmus when reading the Snellen chart:
This is incorrect. Nystagmus is an involuntary, rhythmic oscillation of the eyes, which can be indicative of a neurological or vestibular issue. It is not a normal finding during the diagnostic positions test. Nystagmus may be seen with certain disorders, such as vestibular dysfunction, neurologic damage, or alcohol intoxication, but it should not occur as a normal response to eye movement during the diagnostic positions test.

C) Parallel movement of both eyes:
This is the correct answer. In a normal result of the diagnostic positions test, both eyes should move in parallel and remain aligned during all directions of gaze. The purpose of this test is to assess for any eye muscle weakness or cranial nerve dysfunction that might cause misalignment, such as strabismus or a disorder affecting the extraocular muscles. If both eyes track smoothly and simultaneously without deviation or lag, this is a normal and expected finding.

D) Convergence of the eyes:
This is incorrect. While convergence (the inward movement of both eyes toward the nose) is a normal response when focusing on a near object, it is not the specific goal of the diagnostic positions test. The diagnostic positions test is primarily concerned with assessing the ability of the eyes to move together in all directions of gaze without misalignment or abnormal movement. While convergence is a sign of normal eye function, it is not the primary focus of this particular test.

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Correct Answer is B

Explanation

A) Fifth intercostal space, midaxillary line:
This is incorrect. The fifth intercostal space at the midaxillary line is a location that can be assessed for tactile fremitus, but it is not typically where fremitus is felt most intensely. Fremitus tends to be stronger near the midline structures, such as over the trachea, rather than at this lateral position, which is more peripheral.

B) Between the scapulae:
This is the correct answer. Tactile fremitus is usually most intense over the area between the scapulae and near the sternum. This is because the bronchi and trachea are located close to the chest wall in these regions, creating more intense vibrations that can be palpated during assessment. The fremitus is transmitted through the airways and is easiest to feel when the lung tissue is close to the chest wall, as in the area between the scapulae.

C) Third intercostal space, midaxillary line:
This is incorrect. The third intercostal space at the midaxillary line is not typically the site where tactile fremitus is most prominent. This area is more peripheral, and fremitus tends to be weaker here compared to regions closer to the sternum or between the scapulae where the lungs are nearer to the chest wall.

D) Over the lobes, posterior side:
This is incorrect. While tactile fremitus can be assessed over the posterior lobes of the lungs, it is not generally felt most intensely here. Fremitus is usually stronger near the midline of the chest (sternum) or between the scapulae, and tends to be weaker as you move laterally or toward the lower lobes of the lungs.

A. The best time to perform BSE is immediately prior to the menstrual cycle B. If pregnancy is suspected, BSE should not be performed until post delivery C. The best time to perform BSE is 4 to 7 days after the first day of the menstrual period D. The woman with diagnosed fibrocystic breast tissue should not rely on BSE

Correct Answer is C

Explanation

A) The best time to perform BSE is immediately prior to the menstrual cycle:
Performing a breast self-examination (BSE) immediately prior to the menstrual cycle is not ideal because hormonal changes leading up to menstruation can cause the breasts to become swollen, tender, and lumpy. These changes could make it difficult to detect subtle lumps or changes in the breast tissue. For the most accurate assessment, it's recommended that women avoid performing BSE during the premenstrual phase when the breast tissue is most likely to be affected by hormonal fluctuations.

B) If pregnancy is suspected, BSE should not be performed until post-delivery:
This statement is incorrect. There is no contraindication to performing a breast self-examination during pregnancy, and it is important for pregnant women to continue self-monitoring for any changes in breast tissue. In fact, BSE should be performed regularly during pregnancy, as the breast tissue can undergo changes due to hormonal shifts, and early detection of any abnormalities is key to successful management.

C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period:
This is the correct recommendation. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period because the breasts are least likely to be swollen or tender during this time. Hormonal levels are more stable at this point in the menstrual cycle, and any lumps or changes in the tissue are more likely to be noticeable. Performing BSE during this time increases the likelihood of detecting potential abnormalities.

D) The woman with diagnosed fibrocystic breast tissue should not rely on BSE:
While it is true that women with fibrocystic breast changes may experience lumpy, tender tissue, they should still perform BSE regularly. Fibrocystic tissue can sometimes make it more difficult to distinguish between normal and abnormal changes, but BSE remains an important tool for detecting significant changes, such as new lumps or changes in size, shape, or consistency. Women with fibrocystic breast tissue should be taught to perform BSE regularly and to report any unusual changes to their healthcare provider. Relying solely on BSE for breast cancer detection is not recommended, but it is an essential part of breast health awareness.

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A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for tactile fremitus. The nurse should recognize that it is normal to feel tactile fremitus most intensely over which location?

Correct Answer is B

Explanation

A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

Correct Answer is C

Explanation

A nurse is performing an examination of a client's anterior thorax. The nurse should recall that the trachea bifurcates anteriorly at which location?

A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

A nurse is teaching a client about internal structures of the breast. The should understand that the internal breast consists what structures?

A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

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A nurse is completing an assessment o a client suspected of having a carotid artery blockage. Which of the following techniques should the nurse to assess the client's carotid arteries?

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