The nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Nystagmus in extreme superior gaze

Slight amount of lid lag when moving the eyes from a superior to an inferior position

Parallel movement of both eyes

Convergence of the eyes

Answer and Explanation

The Correct Answer is C

A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.

B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.

C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.

D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.

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Correct Answer is C

Explanation

A. Bronchovesicular breath sounds and normal in that location:

Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.

B. Normally auscultated over the trachea:

This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.

C. Vesicular breath sounds and normal in that location:

Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.

D. Bronchial breath sounds and normal in that location:

Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.

A. When bronchial breath sounds are auscultated in the trachea. B. When the client is experiencing excessive sneezing from a tree pollen allergy. C. When the client is resting in bed and not experiencing respiratory issues. D. When the bronchial tree is is obstructed by secretions.

Correct Answer is D

Explanation

A. When bronchial breath sounds are auscultated in the trachea.

Auscultating bronchial breath sounds in the trachea is a normal finding, as the trachea is close to the upper airway, and this is where bronchial sounds are normally heard. However, if these sounds are heard in the peripheral lung fields, it can indicate an abnormal condition.

B. When the client is experiencing excessive sneezing from a tree pollen allergy.

Excessive sneezing due to allergies would not typically result in increased breath sounds. Allergies may cause nasal congestion, but they don't directly lead to increased breath sounds.

C. When the client is resting in bed and not experiencing respiratory issues.

If a client is at rest and not experiencing any respiratory issues, breath sounds should typically be normal. There would be no reason to expect increased breath sounds in this scenario.

D. When the bronchial tree is obstructed by secretions.

Increased breath sounds, such as wheezing or rhonchi, can be auscultated when there is an obstruction in the bronchial tree due to secretions, narrowing of the airways, or other causes. These sounds are typically abnormal and indicate an issue with air movement through the airways.

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The nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

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