The nurse is speaking to the client and suspects a weakness in eye muscle after observing the eyes cross.
What test should the nurse administer to further assess this problem?
Cover/Uncover test.
Testing peripheral vision.
Snellen chart test.
Weber test.
The Correct Answer is A
Choice A rationale
The Cover/Uncover test is used to assess the presence of strabismus or eye muscle weakness. During this test, one eye is covered while the other eye is observed for movement. The uncovered eye is then observed when the cover is removed. If there is a misalignment or weakness, the uncovered eye will move to re-establish focus, indicating a problem with eye muscle control.
Choice B rationale
Testing peripheral vision involves assessing the range of vision around the central focus point and is not specifically used to detect eye muscle weakness. It evaluates the function of the retina and optic nerve rather than the eye muscles. This test helps identify issues such as glaucoma or retinal detachment.
Choice C rationale
The Snellen chart test measures visual acuity, specifically how well a person can see at various distances. It is not designed to assess eye muscle strength or alignment. The test involves reading letters of different sizes from a chart placed at a standard distance.
Choice D rationale
The Weber test is an auditory test used to assess hearing loss by placing a vibrating tuning fork on the forehead or middle of the head. It helps determine whether hearing loss is conductive or sensorineural in nature. This test does not provide information about eye muscle function or alignment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Rhonchi are low-pitched, coarse sounds typically heard during expiration, associated with secretions in large airways, not high-pitched continuous sounds.
Choice B rationale
Stridor is a high-pitched sound heard during inspiration, typically indicating upper airway obstruction.
Choice C rationale
Wheezes are continuous high-pitched whistling sounds heard during expiration, common in conditions like chronic obstructive pulmonary disease, where airway narrowing is present.
Choice D rationale
Crackles are discontinuous sounds heard during inspiration, usually associated with fluid in the lungs or alveolar opening, not continuous high-pitched sounds. .
Correct Answer is A
Explanation
Choice A rationale
"C" in the ABCDE criteria for assessing skin lesions stands for Color. This criterion refers to the variations in the color of the lesion, which could include shades of black, brown, tan, or even white, red, or blue. Uneven or multiple colors within a single lesion can be a warning sign of melanoma, a type of skin cancer. Regularly checking the color of moles or spots on the skin is crucial for early detection of potential malignancies.
Choice B rationale
Characteristics are not part of the ABCDE criteria. The ABCDE criteria specifically stand for Asymmetry, Border, Color, Diameter, and Evolving. These criteria are used by healthcare professionals to identify suspicious skin lesions that may need further evaluation or biopsy to rule out skin cancer. Focusing on these specific aspects helps in early detection and treatment of malignant skin conditions.
Choice C rationale
Crepitus is a term used to describe a crackling or grating sound or sensation, typically associated with bones or joints, and is not related to skin lesion assessment. Crepitus can be felt or heard in conditions such as arthritis, where the cartilage in the joints has worn away, causing bones to rub against each other. It is unrelated to the ABCDE criteria for skin lesions.
Choice D rationale
Coping methods are strategies used by individuals to manage stress, emotions, or adverse situations and have no relevance to the ABCDE criteria for skin lesions. Coping methods can include techniques like exercise, meditation, or talking to a therapist, but they do not pertain to the physical examination of skin lesions for signs of cancer.
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