A school nurse is assessing the visual acuity of a school-age child. Which of the following findings indicate that the child should be evaluated for strabismus?
Visual acuity 20/30 bilaterally
Peripheral vision 70° downward
Movement of the uncovered eye during a cover test
Light reflects symmetrically within each pupil during a corneal light reflex test
The Correct Answer is C
A. Visual acuity 20/30 bilaterally: Visual acuity of 20/30 bilaterally indicates relatively good vision in both eyes, but it does not necessarily indicate strabismus. Strabismus is related to eye alignment rather than visual acuity.
B. Peripheral vision 70° downward: Peripheral vision refers to the ability to see objects outside the direct line of vision. While changes in peripheral vision can occur in various eye conditions, such as glaucoma, it is not specific to strabismus.
C. Movement of the uncovered eye during a cover test: This is the correct option. During a cover test, one eye is covered while the other eye fixates on an object. If the uncovered eye moves to try to align with the covered eye, it may indicate strabismus or a misalignment of the eyes.
D. Light reflects symmetrically within each pupil during a corneal light reflex test: A corneal light reflex test assesses the alignment of the eyes by observing the reflection of light on the corneas. While asymmetry in the corneal light reflex can indicate strabismus, the description provided in this option suggests that the light reflects symmetrically within each pupil, which is a normal finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Apply a dry gauze dressing twice per day."
This instruction may not be necessary for a hypospadias repair procedure. Typically, the surgical site will have a dressing applied immediately after the surgery, but ongoing dressing changes may not be required once the infant is discharged. It's essential to follow the specific postoperative care plan provided by the healthcare provider.
B. "Perform hourly measurements of the infant's urinary output."
Hourly measurements of urinary output may not be necessary unless specifically instructed by the healthcare provider due to concerns such as urinary retention or dehydration. However, regular monitoring of urinary output as part of routine care may be appropriate.
C. "Offer the infant 12 to 18 ounces of fruit juice daily."
Offering 12 to 18 ounces of fruit juice daily to a 6-month-old infant is not recommended. Introduction of fruit juice should be gradual and in small amounts, following guidance from healthcare providers and infant nutrition guidelines. Excessive fruit juice consumption can lead to gastrointestinal issues and may not be suitable for all infants.
D. "Avoid giving the infant a tub bath until the stent is removed."
This instruction is appropriate. After hypospadias repair surgery, a stent or catheter may be placed to aid in healing and ensure proper urine drainage. It's essential to follow healthcare provider instructions regarding bathing and hygiene to minimize the risk of infection and to ensure the stent remains in place until it is ready to be removed.
Correct Answer is B
Explanation
A. "Honor the child's request if she holds her breath.": This instruction is incorrect and potentially dangerous. Giving in to the child's demands when they hold their breath during a temper tantrum can reinforce the behavior and may lead to more frequent and intense tantrums. It's important for parents to remain calm and not give in to unreasonable demands during tantrums.
B. "Establish a structured daily routine for the child.": This instruction is appropriate. A structured daily routine can help toddlers feel secure and provide predictability, which may reduce the likelihood of tantrums. Consistency in meal times, naptimes, and activities can help toddlers know what to expect and feel more in control of their environment.
C. "Place the child in her room alone until the temper tantrum ends.": While it may be necessary to remove a toddler from a potentially dangerous situation during a tantrum, isolating them in their room alone is not recommended. It's important for parents to stay nearby to ensure the child's safety and to provide comfort and support as needed.
D. "Comfort the child during the temper tantrum.": Providing comfort and reassurance to a child during a temper tantrum can be helpful, as long as it's done in a calm and supportive manner. Reassuring words and gentle touch can help the child feel secure and may help to de-escalate the tantrum more quickly.
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