A nurse needs to assess the peripheral vision of a client. What test is appropriate?

Rosenbaum test

Consensual constriction

Corneal Light Reflex

Confrontation test

Answer and Explanation

The Correct Answer is D

A) Rosenbaum test: The Rosenbaum test is used to assess near vision and is typically performed with a handheld card to check for presbyopia, which is the difficulty seeing up close. It is not appropriate for testing peripheral vision, which is the focus of the current assessment.

B) Consensual constriction: Consensual constriction refers to the reaction of the pupil in the opposite eye when light is shined into one eye. This test assesses the pupillary light reflex, which evaluates how well the pupils constrict in response to light. It is not used to assess peripheral vision and focuses more on the function of the optic nerve and pupil reaction.

C) Corneal Light Reflex: The corneal light reflex is a test used to assess for strabismus (misalignment of the eyes) by checking the symmetry of the light reflection on the cornea. This test helps in diagnosing eye alignment issues, but it does not evaluate peripheral vision.

D) Confrontation test: The confrontation test is a straightforward and effective method used to assess peripheral vision. The nurse and patient sit facing each other, and the patient covers one eye while the nurse tests the other eye’s visual fields by moving their fingers in from the periphery. This test evaluates the patient's ability to detect objects in their peripheral vision and is specifically designed for this purpose.

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Correct Answer is C

Explanation

A) Epistaxis: Epistaxis, or a nosebleed, typically presents with the sudden onset of blood coming from one or both nostrils. Although a nosebleed can cause discomfort and a sense of obstruction, it does not typically present as difficulty breathing through one side of the nose. Epistaxis is more related to trauma, dry air, or nasal irritation rather than a structural issue causing airflow restriction.

B) Perforated septum: A perforated septum refers to a hole or tear in the nasal septum, the cartilage and bone that separates the two nasal passages. It may cause symptoms such as a whistling sound when breathing or increased susceptibility to infections, but difficulty breathing on one side of the nose alone isn't the most common symptom. A perforated septum is often associated with chronic drug use or injury, but it doesn't usually present with unilateral breathing difficulty unless it's very severe.

C) Deviated septum: A deviated septum occurs when the thin wall of bone and cartilage that divides the nasal cavity is displaced to one side. This condition is one of the most common causes of breathing difficulty on one side of the nose. The deviation can obstruct airflow, leading to symptoms like difficulty breathing through one nostril, congestion, or sinus infections. This diagnosis is most likely based on the patient's complaint.

D) Ankyloglossia: Ankyloglossia, also known as tongue-tie, refers to a condition where the frenulum (the membrane under the tongue) is abnormally short, restricting the tongue's movement. While it can cause feeding difficulties in infants or speech issues, it has no connection to nasal airflow or breathing problems. This diagnosis is unrelated to the symptoms described.

A. At the base of the skull B. In front of the ears C. Under the mandible D. Above the clavicles

Correct Answer is A

Explanation

A) At the base of the skull: The occipital lymph nodes are located at the base of the skull, just above the nape of the neck. The nurse should use a gentle circular motion to palpate the area where these lymph nodes are found. This is the correct location to assess for tenderness, swelling, or abnormalities in the occipital lymph nodes.

B) In front of the ears: The lymph nodes located in front of the ears are known as the preauricular lymph nodes. These are not the occipital lymph nodes. The preauricular nodes are assessed by palpating just in front of the ear, not at the base of the skull.

C) Under the mandible: The submandibular lymph nodes are located under the mandible (lower jaw). These nodes are not the occipital lymph nodes. The nurse would need to palpate under the jawline to assess the submandibular area.

D) Above the clavicles: The supraclavicular lymph nodes are located above the clavicles (collarbones), and they are not the occipital lymph nodes. This area is assessed separately to check for lymph node enlargement or abnormal findings.

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A nurse needs to assess the peripheral vision of a client. What test is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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