During an assessment of the eyes, the nurse documents protrusion of both eyeballs. What is the name of this abnormality?
Pterygium
Ptosis
Exophthalmos
Ectropion
The Correct Answer is C
A) Pterygium: A pterygium is a benign growth of tissue on the conjunctiva that can extend onto the cornea. It typically appears as a fleshy, triangular-shaped tissue that can cause irritation or vision problems if it grows large enough. However, it does not involve protrusion of the eyeballs and is unrelated to the condition described in the question.
B) Ptosis: Ptosis refers to the drooping or sagging of the upper eyelid, often due to weakness of the eyelid muscles or nerve damage. It can impair vision by obstructing the visual field, but it does not describe protrusion of the eyeballs, as indicated in the question. Ptosis involves the eyelids, not the position of the eyeball itself.
C) Exophthalmos: Exophthalmos is the term for the abnormal protrusion or bulging of both eyeballs. It is most commonly associated with thyroid eye disease, particularly in conditions such as Graves' disease. The eyes appear to bulge outward due to inflammation or swelling of the tissues behind the eyes. This condition can affect vision and cause discomfort, and it is the correct term for the abnormality described in the question.
D) Ectropion: Ectropion is a condition in which the lower eyelid turns outward, exposing the inner surface of the eyelid. This can lead to irritation, dryness, and potential damage to the cornea. Ectropion does not involve protrusion of the eyeballs, and it is unrelated to the condition described in the question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) 2 mm: A pupil size of 2 mm would be considered small and is generally indicative of miosis, which can occur due to certain medications, increased intracranial pressure, or other factors. A size of 2 mm is not typically expected as a normal finding for pupil size in healthy individuals.
B) 6 mm: While 6 mm is within the upper normal range for pupil size, it is on the larger end. Pupils usually range from 3 mm to 6 mm in size under normal lighting conditions. However, pupils dilating to 6 mm can occur in response to low light conditions or sympathetic stimulation.
C) 8 mm: A pupil size of 8 mm would be considered dilated (mydriasis) and is abnormal under normal lighting conditions. Such a large pupil may suggest conditions like drug use, neurological issues, or other medical concerns that need to be assessed.
D) 4 mm: A pupil size of 4 mm is considered a normal and expected finding under standard lighting conditions. It falls within the typical range for adult pupil size and reflects a healthy, functional response to ambient light conditions. This size is within the commonly observed range for normal pupils.
Correct Answer is B
Explanation
A) Expected finding: Cotton wool spots are not considered an expected finding during a routine eye exam. These spots are indicative of underlying pathology, and their presence typically suggests an abnormality that warrants further investigation. They are not part of normal eye anatomy or typical health.
B) Unexpected finding: Cotton wool spots are small, white, fluffy lesions in the retina that occur due to microinfarctions of retinal nerve fibers. Their presence is considered an unexpected or abnormal finding during an ophthalmoscopic exam and can be associated with several conditions, including diabetes, hypertension, and other systemic diseases that affect blood flow to the retina. Their appearance is a signal of potential underlying health issues that require attention.
C) Expected variation: Cotton wool spots are not a variation of normal anatomy or function. They are pathological and should not be regarded as a normal variation of retinal appearance during an eye exam.
D) Irrelevant: The term "irrelevant" is not applicable in this context, as the presence of cotton wool spots is highly relevant to the clinical assessment. Their discovery suggests a need for further investigation into the patient's overall health, particularly cardiovascular or systemic conditions.
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