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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.

B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.

C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.

A. Simultaneously palpating both arteries to compare amplitude. B. Listening with the diaphragm of the stethoscope to assess for bruits. C. instructing the patient to take slow deep breaths during auscultation. D. Palpating the artery at the base of the neck of the neck.

Correct Answer is B

Explanation

A. Simultaneously palpating both arteries to compare amplitude: While comparing amplitudes is important, using the diaphragm of the stethoscope to listen for bruits (abnormal whooshing sounds indicating turbulent blood flow) is a more specific and accurate method for assessing the carotid arteries for potential vascular issues.

B. Listening with the diaphragm of the stethoscope to assess for bruits: This technique allows the nurse to detect abnormal sounds (bruits) that could indicate partial blockages or stenosis in the carotid arteries, suggesting a risk of stroke or transient ischemic attack.

C. Instructing the patient to take slow deep breaths during auscultation: Deep breaths are more relevant during lung auscultation. Carotid artery assessment focuses on detecting abnormal sounds and assessing blood flow rather than respiratory patterns.

D. Palpating the artery at the base of the neck: Palpation alone does not provide enough information about potential blockages or abnormalities in the carotid arteries. Listening with a stethoscope allows for a more detailed assessment of blood flow and the presence of bruits.f the nurse hears a bruit during auscultation, they shouldnotpalpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?

Correct Answer is A

Explanation

The nurse is completing an assessment on a client suspected of having a transient ischemic attack. Which of the following techniques should the nurse use to assess the client's carotid arteries?

Correct Answer is B

Explanation

The nurse is listening to the breath sounds of young adult client with severe asthma. The nurse recognizes that air passing through narrowed bronchioles would produce which of these adventitious sounds?

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The nurse is doing an examination of a client's anterior thorax. The nurse recognizes that the trachea bifurcates anteriorly at the:

The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:

The nurse is preparing to assess the heart rate on an adult female client. The nurse recognizes that the apical pulse can be assessed in an adult female at which of the following anatomical position?

The nurse recognizes that the following statement is true regarding the internal structures of the breast: The breast is made up of:

The nurse is teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select all that apply)