NURS 190 Physical Assessment Week 4: HEENT and Lymphatics 2026
|WCU
1. During a physical assessment of the eyes, a nurse notes that a patient has a
Snellen chart result of 20/50. How should the nurse interpret this finding?
A. The patient can see at 50 feet what a normal person sees at 20 feet.
B. The patient has perfect vision in the right eye.
C. The patient’s vision is 50% less than normal.
D. The patient can see at 20 feet what a normal person sees at 50 feet.
Answer: D
Rationale: In the Snellen chart notation, the numerator (20) represents the distance from
the chart, and the denominator (50) represents the distance at which a normal eye could
read that line.
2. When assessing for the pupillary light reflex, the nurse shines a light into the
right eye and observes the left pupil constricting. This specific response is
known as:
A. Direct light reflex
B. Accommodation
C. Consensual light reflex
D. Convergence
Answer: C
Rationale: The consensual light reflex is the simultaneous constriction of the opposite
pupil when one eye is exposed to bright light.
,3. A 70-year-old patient complains of a gradual loss of peripheral vision. The
nurse suspects which of the following conditions?
A. Glaucoma
B. Cataracts
C. Macular degeneration
D. Retinal detachment
Answer: A
Rationale: Glaucoma is characterized by increased intraocular pressure which leads to a
gradual loss of peripheral vision, whereas macular degeneration affects central vision.
4. The nurse is performing a Hirschberg test (corneal light reflex) on a child.
What finding would be considered normal?
A. The light is reflected at different spots in each eye.
B. The light is reflected at the 12 o’clock position in both eyes.
C. The light is reflected in exactly the same symmetrical spot on each cornea.
D. The light is reflected only on the iris of the left eye.
Answer: C
Rationale: The Hirschberg test checks for eye alignment; the light should reflect in the
exact same spot on each eye to indicate symmetrical alignment.
5. Which cranial nerves are being tested when the nurse asks the patient to
follow a finger through the six cardinal positions of gaze?
A. II, III, IV
B. III, IV, VI
C. IV, V, VI
D. III, VI, VII
Answer: B
Rationale: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) control the
extraocular muscles responsible for eye movement.
, 6. The nurse observes a patient’s upper eyelid drooping significantly over the
iris. This finding is documented as:
A. Exophthalmos
B. Enophthalmos
C. Ectropion
D. Ptosis
Answer: D
Rationale: Ptosis is the drooping of the upper eyelid, which can be caused by
neuromuscular weakness or cranial nerve III damage.
7. While examining the internal eye with an ophthalmoscope, the nurse should
identify which of the following as a normal finding on the optic disc?
A. A fuzzy, blurred margin
B. A grey, pigmented crescent shape
C. Large pulsations of the retinal veins
D. A color that is creamy yellow-orange to pink
Answer: D
Rationale: A normal optic disc is creamy yellow-orange to pink, round or oval, and has
distinct, sharply demarcated margins.
8. When assessing the ears of an adult, the nurse should pull the pinna in which
direction before inserting the otoscope?
A. Up and back
B. Straight back
C. Down and back
D. Up and forward
Answer: A
Rationale: In adults, the ear canal is straightened by pulling the pinna up and back; for
children under 3, it is pulled down and back.
|WCU
1. During a physical assessment of the eyes, a nurse notes that a patient has a
Snellen chart result of 20/50. How should the nurse interpret this finding?
A. The patient can see at 50 feet what a normal person sees at 20 feet.
B. The patient has perfect vision in the right eye.
C. The patient’s vision is 50% less than normal.
D. The patient can see at 20 feet what a normal person sees at 50 feet.
Answer: D
Rationale: In the Snellen chart notation, the numerator (20) represents the distance from
the chart, and the denominator (50) represents the distance at which a normal eye could
read that line.
2. When assessing for the pupillary light reflex, the nurse shines a light into the
right eye and observes the left pupil constricting. This specific response is
known as:
A. Direct light reflex
B. Accommodation
C. Consensual light reflex
D. Convergence
Answer: C
Rationale: The consensual light reflex is the simultaneous constriction of the opposite
pupil when one eye is exposed to bright light.
,3. A 70-year-old patient complains of a gradual loss of peripheral vision. The
nurse suspects which of the following conditions?
A. Glaucoma
B. Cataracts
C. Macular degeneration
D. Retinal detachment
Answer: A
Rationale: Glaucoma is characterized by increased intraocular pressure which leads to a
gradual loss of peripheral vision, whereas macular degeneration affects central vision.
4. The nurse is performing a Hirschberg test (corneal light reflex) on a child.
What finding would be considered normal?
A. The light is reflected at different spots in each eye.
B. The light is reflected at the 12 o’clock position in both eyes.
C. The light is reflected in exactly the same symmetrical spot on each cornea.
D. The light is reflected only on the iris of the left eye.
Answer: C
Rationale: The Hirschberg test checks for eye alignment; the light should reflect in the
exact same spot on each eye to indicate symmetrical alignment.
5. Which cranial nerves are being tested when the nurse asks the patient to
follow a finger through the six cardinal positions of gaze?
A. II, III, IV
B. III, IV, VI
C. IV, V, VI
D. III, VI, VII
Answer: B
Rationale: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) control the
extraocular muscles responsible for eye movement.
, 6. The nurse observes a patient’s upper eyelid drooping significantly over the
iris. This finding is documented as:
A. Exophthalmos
B. Enophthalmos
C. Ectropion
D. Ptosis
Answer: D
Rationale: Ptosis is the drooping of the upper eyelid, which can be caused by
neuromuscular weakness or cranial nerve III damage.
7. While examining the internal eye with an ophthalmoscope, the nurse should
identify which of the following as a normal finding on the optic disc?
A. A fuzzy, blurred margin
B. A grey, pigmented crescent shape
C. Large pulsations of the retinal veins
D. A color that is creamy yellow-orange to pink
Answer: D
Rationale: A normal optic disc is creamy yellow-orange to pink, round or oval, and has
distinct, sharply demarcated margins.
8. When assessing the ears of an adult, the nurse should pull the pinna in which
direction before inserting the otoscope?
A. Up and back
B. Straight back
C. Down and back
D. Up and forward
Answer: A
Rationale: In adults, the ear canal is straightened by pulling the pinna up and back; for
children under 3, it is pulled down and back.
