The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next?

Assess child's ability to read.

Consider this a normal finding.

Assess the child's visual fields with the confrontation test.

Test for strabismus by performing the corneal light reflex test (Sparkle Test).

Answer and Explanation

The Correct Answer is D

A. Assess child's ability to read: A 2-year-old is too young for a standard reading assessment, as they may not yet recognize letters. Visual acuity tests for this age group typically use pictures or symbols rather than reading letters. Assessing reading ability would not be appropriate or useful in diagnosing strabismus, as the condition affects eye alignment rather than literacy skills.

B. Consider this a normal finding: Strabismus, or "lazy eye," is not a normal finding beyond infancy. If left untreated, it can lead to amblyopia (permanent vision loss in the weaker eye). Early detection and intervention are crucial for proper visual development, and dismissing the finding as normal could result in a missed opportunity for corrective treatment, such as patching or corrective lenses.

C. Assess the child's visual fields with the confrontation test: The confrontation test assesses peripheral vision, not strabismus. It is more appropriate for older children and adults, as it requires the child to understand and follow instructions. While it can identify visual field deficits, it does not evaluate binocular vision or eye misalignment, which are essential in diagnosing strabismus.

D. Test for strabismus by performing the corneal light reflex test (Sparkle Test): The corneal light reflex test evaluates eye alignment by shining a light at the child's eyes and observing the reflection on the corneas. If the light reflex is asymmetrical, it suggests strabismus, which requires further evaluation and possible treatment. Early detection is critical to prevent amblyopia, and this simple test is a quick and effective method to screen for misalignment in young children.

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Correct Answer is C

Explanation

A. Behind with the nurse's hands placed firmly around his neck: This approach may be perceived as threatening or invasive, potentially increasing the patient's apprehension and discomfort. It is important to maintain a respectful and gentle approach, especially when working with a patient who may already feel uneasy.

B. Behind with hands placed on throat: Similar to option A, examining from behind and placing hands on the throat may cause anxiety and discomfort for the patient, particularly if they are not familiar with the procedure. This method does not provide a clear line of sight or reassurance for the patient.

C. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward: This technique is the most appropriate approach for examining the thyroid gland. Positioning the patient in front allows for better communication and visibility. Placing the thumbs on either side of the trachea is a standard method for palpating the thyroid, and having the patient tilt their head forward can help relax the neck muscles, making the examination more comfortable. Additionally, this approach allows the nurse to explain the procedure more easily, even with language barriers.

D. Have the patient perform the exam: While patient involvement in their care can be empowering, asking the patient to perform the exam may not be appropriate for a thyroid examination, as the nurse must assess the gland's size, consistency, and any potential nodules. This approach may also lead to further anxiety for the patient, who may not know how to perform the exam correctly.

A. Bronchophony B. Wheezes C. Bronchial sounds D. Whispered pectoriloquy

Correct Answer is B

Explanation

A. Bronchophony: Bronchophony is an increase in clarity of spoken sounds when auscultating the lungs, typically indicating lung consolidation or pathology. It is not an adventitious sound associated with airflow through narrowed bronchioles.

B. Wheezes: Wheezes are high-pitched, musical sounds that occur when air passes through narrowed or obstructed airways, such as in cases of severe asthma. They are often heard during expiration and indicate bronchoconstriction or inflammation in the airways. This is the correct answer for the scenario presented.

C. Bronchial sounds: Bronchial sounds are normal breath sounds typically heard over the trachea and major bronchi. They are characterized by a higher pitch and a hollow quality. They are not classified as adventitious sounds and are not indicative of asthma.

D. Whispered pectoriloquy: Whispered pectoriloquy is a clinical finding where whispered sounds are heard more clearly over areas of lung consolidation. Like bronchophony, it does not represent an adventitious sound caused by airflow through narrowed bronchioles and is more indicative of lung pathology.

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The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland?

Correct Answer is C

Explanation

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Correct Answer is B

Explanation

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