During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes.
The nurse should recognize that this is:.
A normal finding
An abnormal finding: the child needs referral to an ophthalmologist
A sign of a possible visual defect; the child needs vision screening
A sign of small hemorrhages, which usually resolve spontaneously
The Correct Answer is A
A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.
Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.
Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.
A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.
Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.
Hemorrhages can be caused by diabetes, hypertension, or trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Brian playing with his truck next to Kristina playing with her truck. This is because parallel play is when children play side by side with similar toys but do not interact with each other. Parallel play is typical for toddlers and preschoolers.
Choice A is wrong because Kimberly and Amanda sharing clay to each make things is an example of cooperative play, which involves sharing, taking turns, and following
rules. Cooperative play is typical for school-age children.
Choice C is wrong because Adam playing a board game with Kyle, Steven, and Erich is also an example of cooperative play, as they are playing by the same rules and interacting with each other.
Choice D is wrong because Danielle playing with a music box on her mother’s lap is an example of solitary play, which is when a child plays alone and does not seek contact with others. Solitary play is typical for infants.
Correct Answer is A
Explanation
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen. Estrogen increases blood flow and causes the nasal mucosa to swell, leading to congestion and nosebleeds. This condition is called pregnancy rhinitis and affects up to 20% of pregnant women.
Choice B is wrong because this is not an abnormal cardiovascular change, and the nosebleeds are not an ominous sign. They are usually harmless and do not affect the pregnancy outcome.
Choice C is wrong because there is no evidence that the woman is a victim of domestic violence.
This is a serious accusation that should not be made without proper assessment and screening.
Choice D is wrong because there is no indication that the woman has been using cocaine intranasally. Cocaine use can cause nasal damage and bleeding, but it can also have other signs and symptoms such as agitation, euphoria, dilated pupils, increased heart rate and blood pressure, and risk of miscarriage or preterm labor.
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