Answers Graded A+ Set 2026
1. What is the normal response to the accommodation a. Convergence of the axis
test? of the eyes and constric-
tion of the pupils
a. Convergence of the axis of the eyes and constriction
of the pupils
b. A direct light reflex and consensual light reflex
c. Conjugate movement of the eyes in all 6 cardinal
positions of gaze
d. Symmetrical dilation of bilateral pupils
2. How will the nurse assess the peripheral vision of an d. Perform the confronta-
adult patient who was admitted to the hospital with a tion test
possible stroke?
a. Perform the Snellen alphabet test
b. Perform the diagnostic positions test
c. Perform the corneal light reflex test
d. Perform the confrontation test
3. Which cranial nerves are being tested when the nurse a. Cranial nerves III, IV and
has a patient perform the diagnostic positions test? VI
a. Cranial nerves III, IV and VI
b. Cranial nerves II, III and IV
c. Cranial nerves IV, V and VI
d. Cranial nerves III, IV and V
4. What is the best nursing response when asymmetric b. Refer the patient to the
corneal light reflex is observed in a 3 year old child? appropriate specialist due
to strabismus
a. Look for other signs of Bell's palsy
b. Refer the patient to the appropriate specialist due
to strabismus
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c. No action is needed, because this is a normal finding
in children under the age of 6
d. Notify the physician of cranial nerve II dysfunction
5. What is the nursing priority for an African-American c. Proceed with the ex-
patient with small brown macules on the sclera? amination as planned be-
cause this is a normal
a. Refer the patient to an ophthalmologist for further finding.
testing.
b. Notify the patient that he may have liver disease
and should have it checked.
c. Proceed with the examination as planned because
this is a normal finding.
d. Instruct the patient to wear sunglasses when out-
doors to prevent further macule formation.
6. How will the nurse document assessment of the eyes b. Ptosis of the left eye lid
in an adult patient that has drooping of the left eye lid
with a smaller distance between the upper and lower
lids on the left?
a. Exophthalmos of the right eye
b. Ptosis of the left eye lid
c. Anisocoria of the left eye lid
d. Nystagmus of the left eye
7. What is the priority nursing intervention when the d. Refer patient for fur-
nurse observes that an elderly patient cannot move ther testing due to possi-
the eyes past the midline to the left when performing ble dysfunction of cranial
the diagnostic positions test? nerves III, IV and VI.
a. Perform the Snellen eye test and pupillary light
reflex to further test cranial nerve II.
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b. Document dysfunction of cranial nerves II and III
and proceed with the assessment.
c. Continue the assessment, because this is a normal
finding in elderly patients.
d. Refer patient for further testing due to possible
dysfunction of cranial nerves III, IV and VI.
8. What type of vision loss does the nurse expect in a a. Visual field loss in the
patient that has experienced an infarct involving the right temporal and left
left cerebral optic tract (left hemispheric stroke)? nasal fields
a. Visual field loss in the right temporal and left nasal
fields
b. Visual field loss in the right nasal and left nasal
fields
c. Visual field loss in the right temporal and left tem-
poral fields
d. Visual field loss in right nasal and left temporal
fields
9. The mother of a 2-year-old is concerned because her d. "Your son's eustachian
son has had three ear infections in the past year. What tube is shorter and wider
would be an appropriate response by the nurse? than yours because of his
age, which allows for in-
a. fections to develop more
"It is unusual for a small child to have frequent ear easily."
infections unless something else is wrong."
b.
"We need to check the immune system of your son to
determine why he is having so many ear infections."
c.
"Ear infections are not uncommon in infants and tod-
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dlers because they tend to have more cerumen in the
external ear."
d.
"Your son's eustachian tube is shorter and wider than
yours because of his age, which allows for infections
to develop more easily."
10. How does the nurse interpret the following informa- d. Vertigo and the inner
tion: an adult patient states that he has the sensation ear is responsible for this
that everything around him is spinning? sensation
a.
Dizziness caused by cranial nerve VIII dysfunction
b.
Vertigo and the middle ear is responsible for this sen-
sation
c.
Near syncope caused by dysfunction of the organ of
Corti
d.
Vertigo and the inner ear is responsible for this sensa-
tion
11. What is the nursing priority when the family of a 2 year a.
old child states that he cannot produce any intelligible Refer the patient to the
speech and is inattentive in conversation? appropriate specialist due
to possible hearing loss
a.
Refer the patient to the appropriate specialist due to
possible hearing loss
b.
Note the placement of the ears, to assess for possible