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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Anteroposterior-to-transverse diameter ratio of 1:1: In COPD, chronic air trapping leads to hyperinflation of the lungs, causing a "barrel chest" appearance where the anteroposterior (AP) diameter approaches or equals the transverse diameter (1:1 ratio). This is a hallmark physical finding in advanced stages of the disease.

B. Unequal chest expansion: COPD causes diffuse rather than localized lung pathology, leading to generally reduced but symmetrical chest expansion. Unequal expansion is more characteristic of conditions like pneumothorax, pleural effusion, or unilateral lung consolidation.

C. Atrophied neck and trapezius muscles: Patients with COPD often develop hypertrophy of the neck and accessory muscles due to chronic respiratory effort, not atrophy. These muscles become more prominent as they assist with breathing, especially during exacerbations.

D. Increased tactile fremitus: Fremitus is the vibration felt on the chest wall when a patient speaks. In COPD, hyperinflation and air trapping decrease lung density, leading to reduced tactile fremitus. Increased fremitus is typically found in conditions with lung consolidation, such as pneumonia.

A. Perform the confrontation test. B. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches. C. Ask the patient to read the print on a handheld Jaeger card. D. Use the Snellen chart positioned 20 feet away from the patient.

Correct Answer is D

Explanation

A. Perform the confrontation test: The confrontation test is used to assess peripheral vision rather than overall visual acuity. It is not the standard method for measuring visual acuity in routine physical examinations.

B. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches: While this can be useful for assessing near vision, it does not provide a complete assessment of visual acuity, which includes both near and distance vision.

C. Ask the patient to read the print on a handheld Jaeger card: The Jaeger card is specifically used for assessing near vision. While it is useful for determining how well the patient can see up close, it does not assess distance visual acuity, which is typically required in routine examinations for teenagers.

D. Use the Snellen chart positioned 20 feet away from the patient: The Snellen chart is the standard tool for measuring distance visual acuity. It is positioned 20 feet away from the patient to evaluate how well they can see letters of various sizes. This method provides a clear assessment of the patient’s visual acuity for routine physical examinations.

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The nurse is performing the diagnostic positions test (6 Cardinal Gazes). Which result is a normal finding?

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