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 C
Explanation
A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.
B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.
C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.
D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.
Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}
Explanation
|
Assessment Technique |
1 |
2 |
3 |
4 |
|
Percussion |
✅ |
|||
|
Inspection |
✅ |
|||
|
Palpation |
✅ |
|||
|
Auscultation |
✅ |
Rationale:
Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
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