The nurse is performing the diagnostic positions test (6 Cardinal Gazes). Which result is a normal finding?
Nystagmus in extreme superior gaze
Slight amount of lid lag when moving the eyes from a superior to an inferior position
Convergence of the eyes
Parallel/synchronized movement of both eyes
The Correct Answer is D
A. Nystagmus in extreme superior gaze: A few beats of nystagmus in extreme lateral gaze may be normal, but sustained nystagmus, especially in superior gaze, suggests neurological impairment such as vestibular dysfunction or multiple sclerosis.
B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag, where the upper eyelid lags behind the downward movement of the eye, is often associated with hyperthyroidism (e.g., Graves' disease). It is not a normal finding in the diagnostic positions test.
C. Convergence of the eyes: Convergence is assessed when a person focuses on a near object, such as during an accommodation test. The diagnostic positions test evaluates extraocular muscle function and cranial nerves III, IV, and VI, focusing on coordinated movement rather than convergence.
D. Parallel/synchronized movement of both eyes: The normal finding in the diagnostic positions test is smooth, coordinated movement of both eyes in all six cardinal directions without lagging, misalignment, or significant nystagmus. This indicates intact extraocular muscles and proper cranial nerve function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation: This method is not ideal because it does not allow the nurse to assess both inhalation and exhalation at each site. It is important to listen to both phases of respiration to evaluate the quality of breath sounds accurately.
B. Instructing the patient to breathe in and out rapidly while listening to the breath sounds: Rapid breathing can alter breath sounds and may not provide an accurate assessment of normal respiratory patterns. The patient should breathe normally to ensure the nurse can correctly evaluate the breath sounds.
C. If the patient is modest, listening to sounds over his or her clothing or hospital gown: It is important to listen directly to the skin to obtain clear breath sounds. Clothing can muffle sounds and interfere with the accuracy of the assessment, so the nurse should ensure that the area is adequately exposed while maintaining the patient's modesty.
D. Listening to at least one full respiration in each location: This is the correct approach to auscultation. By listening to a full breath cycle at each auscultation site, the nurse can accurately assess the quality and characteristics of the breath sounds, including any abnormal findings.
Correct Answer is C
Explanation
A. Bell palsy: Bell palsy is characterized by sudden, unilateral facial weakness or paralysis, usually affecting one side of the face. While it can impact sensation, the inability to differentiate between sharp and dull stimuli on both sides of the face suggests a more systemic issue rather than just Bell palsy.
B. Scleroderma: Scleroderma is a systemic autoimmune disease that affects connective tissue, leading to skin thickening and changes in blood flow. While it can cause skin changes and discomfort, it does not specifically result in the loss of the ability to differentiate sharp and dull sensations in a localized manner.
C. Damage to the trigeminal nerves: The trigeminal nerve (cranial nerve V) is responsible for sensory perception in the face, including the ability to differentiate between sharp and dull sensations. Damage to this nerve can lead to loss of sensation or altered sensation in the facial region. The bilateral nature of the symptoms suggests a central or systemic cause affecting the trigeminal pathways.
D. Frostbite with resultant paresthesia to the cheeks: Frostbite typically causes localized tissue damage and would more likely present with symptoms specific to the affected areas, such as numbness, discoloration, or blistering. While frostbite can lead to sensory changes, it would not typically result in a generalized inability to differentiate sensations on both sides of the face.
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