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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.

B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.

C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.

D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.

A. Tympany to percussion over the intestines B. Loose, watery stool C. Suprapubic tenderness D. A non-palpable spleen E. Aortic pulsation in the epigastric area F. Decreased bowel sounds

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"}}

Explanation

Each category must have at least 1 response option selected

Finding	Normal	Abnormal
Tympany to percussion over the intestines	✅
Loose, watery stool		✅
Suprapubic tenderness		✅
A non-palpable spleen	✅
Aortic pulsation in the epigastric area	✅
Decreased bowel sounds		✅

Rationale:

Tympany to percussion over the intestines (Normal):

Tympany is expected due to the presence of gas in the intestines.

Loose, watery stool (Abnormal):

This is indicative of diarrhea, which may point to gastrointestinal upset or infection.

Suprapubic tenderness (Abnormal):

Tenderness in this area may indicate bladder infection, inflammation, or pelvic issues.

A non-palpable spleen (Normal):

The spleen is generally not palpable in healthy individuals unless it is enlarged (splenomegaly).

Aortic pulsation in the epigastric area (Normal):

Mild pulsations may be felt in thin or normal-weight individuals. However, a widened or strong pulsation could suggest an abdominal aortic aneurysm.

Decreased bowel sounds (Abnormal):

Hypoactive or absent bowel sounds may indicate decreased intestinal motility, such as in ileus or peritonitis.

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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:

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Naxlex Comprehensive Predictor Exams

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"}}

Explanation

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

In performing a voice test to assess hearing, which of these actions would the nurse perform?

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?