During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:
May indicate disease of the cerebellum or brainstem.
is a sign that the patient is nervous about the examination
Indicates a visual problem, and a referral to an ophthalmologist is indicated.
is a normal occurrence
The Correct Answer is A
A. Severe nystagmus is often associated with neurological disorders, particularly those affecting the cerebellum or brainstem.
B. is a sign that the patient is nervous about the examination. Nervousness typically doesn’t cause severe, persistent nystagmus.
C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. While nystagmus affects vision, it is usually neurologically based, requiring a neurological assessment rather than a referral to an ophthalmologist.
D. Nystagmus is not typically normal, especially when it is severe and persistent. It warrants further investigation.
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Related Questions
Correct Answer is D
Explanation
A. A tear in the rotator cuff usually results in pain and limited range of motion, but it doesn't typically cause a length discrepancy in the arms.
B. Also known as frozen shoulder, this condition is characterized by limited range of motion but would not cause a discrepancy in arm length.
C. While joint effusion involves fluid accumulation and can cause pain and swelling, it doesn't cause arm length discrepancy or the sudden inability to move the shoulder.
D. A dislocated shoulder often results in an obvious deformity, such as a length discrepancy between the arms, and could prevent movement due to pain.
Correct Answer is A
Explanation
A. Palpation should be done after auscultation to avoid altering the bowel sounds. Palpation can cause changes in the sounds, making it difficult to assess accurately.
B. It is advisable to auscultate bowel sounds when the patient is not actively eating, so this action is appropriate.
C. This is the correct duration for assessing bowel sounds. Auscultating for 3-5 minutes is within the standard practice.
D. If the client has an NG tube, clamping it before auscultation is appropriate as it prevents additional noises or interference from the tube.
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