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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Whisper a set of random numbers and letters, and then ask the patient to repeat them: The whispered voice test is a simple and reliable screening method for hearing loss. The nurse stands about 2 feet behind the patient, whispers a series of random numbers or letters, and asks the patient to repeat them. This helps assess high-frequency hearing loss.
B. Shield the lips so that the sound is muffled: While the test is performed without the patient seeing the nurse’s lips to prevent lip reading, deliberately muffling the sound is unnecessary and may alter the accuracy of the assessment.
C. Stand approximately 6 feet away to ensure that the patient can really hear at this distance: The whispered voice test is conducted at a standard distance of about 2 feet, not 6 feet. Increasing the distance may make the test unreliable.
D. Ask the patient to place his or her finger in their ears to occlude outside noise: The test should be performed in a quiet environment, but instructing the patient to occlude their ears is unnecessary. Instead, the nurse tests one ear at a time by covering the opposite ear.
Correct Answer is B
Explanation
A. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles: It is normal for older adults to experience changes in hair growth, including loss of eyebrow hair due to a decrease in hair follicles. This finding is considered a typical age-related change and not abnormal.
B. Unequal pupillary constriction in response to light: This finding is considered abnormal and may indicate a potential neurological issue or damage to the optic or oculomotor nerves. Normal pupillary response should be equal and reactive to light, so any discrepancy in pupillary constriction warrants further evaluation.
C. Decrease in tear production: A decrease in tear production is common in older adults due to age-related changes in lacrimal gland function. This condition, known as dry eye syndrome, is not considered abnormal for this age group.
D. Presence of arcus senilis observed around the cornea: Arcus senilis is characterized by a gray or white ring around the cornea due to lipid deposits and is commonly seen in older adults. While it may indicate elevated cholesterol levels in younger individuals, its presence in elderly patients is usually not abnormal.
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