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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A way to establish rapport. Doing a simple magic trick using gauze is a way to gain the child’s trust and attention, and to make the dressing change less stressful and more fun. This is appropriate for a 5-year-old child who is in the stage of initiative versus guilt according to Erikson’s theory of psychosocial development.

Choice A is wrong because 5-year-old children are curious and imaginative, and they enjoy magic tricks and fantasy play.

Choice C is wrong because a simple magic trick is not too distracting, but rather a way to engage the child and reduce anxiety.

Choice D is wrong because a simple magic trick is not inappropriate due to the child’s cognitive development. According to Piaget’s theory of cognitive development, 5-year-old children are in the preoperational stage, which means they can use symbols and language to represent objects and events.

A magic trick using gauze is a symbolic representation of something else, which the child can understand and appreciate.

A. Relieving constipation B. Allowing the adolescent to make decisions about whether or not to take medication C. Verbalizing the importance of monitoring for medication side effects D. Developing alternative educational goals

Correct Answer is C

Explanation

Verbalizing the importance of monitoring for medication side effects.

Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.

Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.

Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.

Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.

Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.

However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.

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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:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as:

Correct Answer is B

Explanation

What is the priority nursing goal for a 14-year-old diagnosed with Graves’ disease?

Correct Answer is C

Explanation

The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.).

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The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect?

An Apgar score of 10 at 1 minute after birth would indicate a(n):

Which infant would be more likely to have Rh incompatibility?

Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?

The nurse is performing an assessment on a child and notes the presence of Koplik’s spots. In which communicable disease are Koplik’s spots present?

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:.