NUR 2092/NUR2092 Exam 3 V3 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. During a physical exam, the nurse notes the patient has an enlarged thyroid gland. What is
the next step the nurse should take?
A. Auscultate the thyroid for a bruit using the bell of the stethoscope.
B. Palpate the gland more deeply to identify nodules.
C. Instruct the patient to perform range of motion exercises for the neck.
D. Document the finding as normal for a middle-aged adult.
Correct Answer: A
Expert Explanation: If the thyroid gland is enlarged, the nurse should auscultate it for a
bruit. A bruit is a soft, pulsatile, whooshing sound heard best with the bell of the
stethoscope. This sound indicates hypervascularity of the gland, which is common in
hyperthyroidism.
2. The nurse is testing a patient’s visual acuity using the Snellen chart. The patient’s vision is
recorded as 20/40. How should the nurse interpret this finding?
A. The patient can see at 20 feet what a normal eye sees at 40 feet.
B. The patient has perfect vision in the right eye but not the left.
C. The patient can see at 40 feet what a normal eye sees at 20 feet.
,D. The patient is legally blind and requires immediate referral.
Correct Answer: A
Expert Explanation: In the Snellen chart fraction, the top number indicates the distance
the person is standing from the chart (20 feet). The bottom number gives the distance at
which a normal eye could have read that particular line. Therefore, 20/40 means the
patient can see at 20 feet what a person with normal vision can see at 40 feet.
3. Which cranial nerves are responsible for the extraocular movements (EOMs) of the eyes?
A. CN II, III, and IV
B. CN I, II, and III
C. CN V, VII, and VIII
D. CN III, IV, and VI
Correct Answer: D
Expert Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens)
control the six muscles that move the eye. The nurse assesses these by having the patient
follow a finger through the six cardinal positions of gaze. Intact movement indicates that
these three cranial nerves and the extraocular muscles are functioning correctly.
4. A nurse is assessing a patient’s pupillary response. When the light is shone into the right
eye, both pupils constrict. How should the nurse document the constriction of the left pupil?
A. Direct light reflex
, B. Accommodation reflex
C. Consensual light reflex
D. Convergence
Correct Answer: C
Expert Explanation: The pupillary light reflex consists of two components: direct and
consensual. The direct light reflex is the constriction of the pupil that receives the light
stimulus directly. The consensual light reflex is the simultaneous constriction of the other
pupil, which indicates an intact pathway through the brainstem.
5. While examining an older adult, the nurse notes a white, cloudy opacity over the lens of
the eye. What is this condition called?
A. Glaucoma
B. Macular degeneration
C. Cataract
D. Presbyopia
Correct Answer: C
Expert Explanation: A cataract is an opacity or clouding of the crystalline lens of the eye. It
is commonly associated with aging and results in blurred vision or glare. Unlike glaucoma,
which involves increased intraocular pressure, cataracts directly affect the clarity of the
lens.
Assessment Q&A with Rationale |
Rasmussen University
1. During a physical exam, the nurse notes the patient has an enlarged thyroid gland. What is
the next step the nurse should take?
A. Auscultate the thyroid for a bruit using the bell of the stethoscope.
B. Palpate the gland more deeply to identify nodules.
C. Instruct the patient to perform range of motion exercises for the neck.
D. Document the finding as normal for a middle-aged adult.
Correct Answer: A
Expert Explanation: If the thyroid gland is enlarged, the nurse should auscultate it for a
bruit. A bruit is a soft, pulsatile, whooshing sound heard best with the bell of the
stethoscope. This sound indicates hypervascularity of the gland, which is common in
hyperthyroidism.
2. The nurse is testing a patient’s visual acuity using the Snellen chart. The patient’s vision is
recorded as 20/40. How should the nurse interpret this finding?
A. The patient can see at 20 feet what a normal eye sees at 40 feet.
B. The patient has perfect vision in the right eye but not the left.
C. The patient can see at 40 feet what a normal eye sees at 20 feet.
,D. The patient is legally blind and requires immediate referral.
Correct Answer: A
Expert Explanation: In the Snellen chart fraction, the top number indicates the distance
the person is standing from the chart (20 feet). The bottom number gives the distance at
which a normal eye could have read that particular line. Therefore, 20/40 means the
patient can see at 20 feet what a person with normal vision can see at 40 feet.
3. Which cranial nerves are responsible for the extraocular movements (EOMs) of the eyes?
A. CN II, III, and IV
B. CN I, II, and III
C. CN V, VII, and VIII
D. CN III, IV, and VI
Correct Answer: D
Expert Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens)
control the six muscles that move the eye. The nurse assesses these by having the patient
follow a finger through the six cardinal positions of gaze. Intact movement indicates that
these three cranial nerves and the extraocular muscles are functioning correctly.
4. A nurse is assessing a patient’s pupillary response. When the light is shone into the right
eye, both pupils constrict. How should the nurse document the constriction of the left pupil?
A. Direct light reflex
, B. Accommodation reflex
C. Consensual light reflex
D. Convergence
Correct Answer: C
Expert Explanation: The pupillary light reflex consists of two components: direct and
consensual. The direct light reflex is the constriction of the pupil that receives the light
stimulus directly. The consensual light reflex is the simultaneous constriction of the other
pupil, which indicates an intact pathway through the brainstem.
5. While examining an older adult, the nurse notes a white, cloudy opacity over the lens of
the eye. What is this condition called?
A. Glaucoma
B. Macular degeneration
C. Cataract
D. Presbyopia
Correct Answer: C
Expert Explanation: A cataract is an opacity or clouding of the crystalline lens of the eye. It
is commonly associated with aging and results in blurred vision or glare. Unlike glaucoma,
which involves increased intraocular pressure, cataracts directly affect the clarity of the
lens.
