When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
Stops any movement, and appears to listen for the sound
Consider this a normal finding.
Shows no obvious response to the noise.
Shows a startle and acoustic blink reflex.
The Correct Answer is B
A. Stops any movement, and appears to listen for the sound: This does not relate to the corneal light reflex test.
B. Consider this a normal finding: Symmetric light reflection at the same clock position in both eyes indicates normal alignment of the eyes.
C. Shows no obvious response to the noise: This response is unrelated to the corneal light reflex test.
D. Shows a startle and acoustic blink reflex: This describes a normal response to a loud noise, not the corneal light reflex test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ptosis: Drooping of the upper eyelid, often caused by nerve or muscle dysfunction.
B. Ectropion: This condition results from age-related weakening of eyelid muscles or facial nerve palsy, causing the lower eyelid to turn outward, exposing the conjunctiva.
C. Exophthalmos: Protrusion of the eyeball, commonly seen in conditions like Graves' disease.
D. Entropion: Inward rolling of the eyelid, leading to eyelashes rubbing against the eye.
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
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