Exam 2: NR302/ NR 302 Health Assessment I
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Q: A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean
that the patient:
Answer:
Has poor vision
Q: 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:
Answer:
Consider this a normal finding
Q: The nurse is performing the diagnostic positions test. Normal findings would be which of
these results?
Answer:
Parallel movement of both eyes
Q: During an assessment of the sclera of a black patient, the nurse would consider which of
these an expected finding?
Answer:
Presence of small brown macules on the sclera
Q: A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has
ptosis of one eye. How should the nurse check for this?
Answer:
Observe the distance between the palpebral fissures.
Q: During an examination of the eye, the nurse would expect what normal finding when
assessing the lacrimal apparatus?
Answer:
Absence of drainage from the puncta when pressing against the inner orbital rim
Q: When assessing the pupillary light reflex, the nurse should use which technique?
Answer:
Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
Q: The nurse is assessing a patients eyes for the accommodation response and would expect to
see which normal finding?
Answer:
Convergence of the axes of the eyes
Q: In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the
patients pupils. On the basis of this finding, the nurse would:
Answer:
Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.
Q: The nurse is examining a patients retina with an ophthalmoscope. Which finding is
considered normal?
Answer:
Optic disc that is a yellow-orange color
Q: A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The
nurse would:
Answer:
Consider this a normal finding
Q: The nurse is assessing color vision of a male child. Which statement is correct? The nurse
should:
Answer:
Test for color vision screening at the Childs 2-year checkup
Q: The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-
year-old child, the nurse suspects that the child has a lazy eye and should:
Answer:
Test for strabismus by performing the corneal light reflex test
Q: The nurse is performing an eye assessment on an 80-year-old patient. Which of these
findings is considered abnormal?
Answer:
Unequal pupillary constriction in response to light
Q: The nurse notices the presence of periorbital edema when performing an eye assessment on
a 70-year-old patient. The nurse should:
Answer:
Ask the patient if he or she has a history of heart failure.
Q: When a light is directed across the iris of a patients eye from the temporal side, the nurse is
assessing for:
Answer:
Presence of shadows, which may indicate glaucoma.
Q: In a patient who has anisocoria, the nurse would expect to observe:
Answer:
Pupils of unequal size.
Q: A patient comes to the emergency department after a boxing match, and his left eye is
swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant
see well from his left eye. The physician suspects retinal damage. The nurse recognizes that
signs of retinal detachment include:
Answer:
Shadow or diminished vision in one quadrant or one half of the visual field.
Q: A patient comes into the clinic complaining of pain in her right eye. On examination, the
nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse
recognizes that this is a
Answer:
Hordeolum (stye)