In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. Based on this finding, what should the nurse do?

Check the light source of the ophthalmoscope to verify that it is functioning

Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina

Suspect that an opacity is present in the lens or cornea

Stop the ophthalmoscopic examination, and refer the patient for further evaluation

Answer and Explanation

The Correct Answer is B

Choice A reason: Checking the ophthalmoscope’s light source is unnecessary unless the device malfunctions. The red glow is a normal finding, reflecting light off the retina’s blood vessels, not indicating equipment issues, making this an inappropriate action.

Choice B reason: The red glow, or red reflex, is a normal finding during ophthalmoscopy, caused by light reflecting off the vascular retina. It indicates a clear optical pathway, ruling out opacities like cataracts, making this the correct action to document as normal.

Choice C reason: An opacity in the lens or cornea (e.g., cataract or corneal scar) would block the red reflex, causing a dark or absent glow. The presence of a red glow indicates a clear media, making this suspicion incorrect.

Choice D reason: Stopping the exam and referring the patient is unwarranted, as the red glow is a normal finding. Referral is only needed for abnormal findings like absent reflex or opacities, making this an unnecessary and incorrect action.

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Correct Answer is A

Explanation

Choice A reason: Tenderness in the right lower quadrant on light palpation is a classic sign of appendicitis, as the appendix is located in this region. Inflammation causes localized peritoneal irritation, leading to pain, which may be accompanied by rebound tenderness or guarding, making this the correct structure.

Choice B reason: The spleen is located in the left upper quadrant, not the right lower quadrant. Tenderness in the right lower quadrant does not correspond to splenic pathology, such as splenomegaly or rupture, making this an incorrect structure for the described finding.

Choice C reason: The gallbladder is in the right upper quadrant, where tenderness might suggest cholecystitis. Right lower quadrant tenderness does not align with gallbladder pathology, as its anatomical location is distinct, making this an incorrect structure for the observed symptom.

Choice D reason: The spine is a midline structure, and tenderness in the right lower quadrant is unrelated to spinal pathology. Spinal issues typically cause back or radicular pain, not localized abdominal tenderness, making this an incorrect choice for the finding.

A. A 15-year-old female soccer player with a broken leg B. A 4-month-old with bruises on the arms C. An 8-year-old gymnast with a broken right arm D. A 2-year-old with bruises on the knees

Correct Answer is B

Explanation

Choice A reason: A 15-year-old soccer player with a broken leg likely sustained the injury during sports, a common occurrence. Bruises on a 4-month-old’s arms are more concerning, as infants are non-mobile and less likely to bruise accidentally, suggesting possible abuse.

Choice B reason: Bruises on a 4-month-old’s arms are highly concerning, as infants this age are not mobile and cannot self-injure. Such bruising may indicate non-accidental trauma or abuse, requiring immediate investigation, making this the most concerning patient for possible abuse.

Choice C reason: An 8-year-old gymnast with a broken arm may have been injured during gymnastics, a plausible accident. A 4-month-old with arm bruises is more alarming, as infants are less likely to bruise without external force, so this is less concerning.

Choice D reason: A 2-year-old with knee bruises is typical from active play or falls while learning to walk. Bruises on a non-mobile 4-month-old’s arms are more suspicious for abuse, making this less concerning than the infant’s situation.

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In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. Based on this finding, what should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?

Correct Answer is A

Explanation

The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be most concerned about possible abuse?

Correct Answer is B

Explanation

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