Florida State College at Jacksonville
NUR 3094C Health Assessment FINAL
EXAM Latest 2024.2025 FSCJ 100%
GRADED A+
The nurse is performing a neurological check on a client with a head injury
from a motor vehicle accident four hours ago. The nurse suspects the
client has developed increased intracranial pressure. Which of the
following would lead the nurse to suspect this diagnosis?
Fixed and dilated pupils
The nurse notes decorticate posturing in a client following a traumatic
brain injury. Which of the following assessments by the nurse would be
consistent with this posturing?
Flexion of the elbows
The nurse is performing hourly assessments of the client's level of
consciousness. During the assessment, the client remains unresponsive
after multiple attempts of the nurse calling their name. Which of the
following would the nurse perform next?
Gently shake the client's shoulders.
,Florida State College at Jacksonville
The nurse is assessing a client's cranial nerves XI (spinal accessory).
Which of the following would the nurse expect to observe?
The client is able to shrug shoulders against resistance
The nurse is preparing to assess the abstract reasoning of a client who
has a diagnosis of early stage Alzheimer disease. Which of the following
questions would be most appropriate for the nurse to ask?
"How are an apple and orange the same?"
As part of a mental status assessment, the nurse asks the client how they
would respond if they found a wallet lying on the sidewalk. This will allow
the nurse to assess which domain of mental status?
Judgment
The nurse records a client's visual acuity as 20/50 using the Snellen eye
chart. The nurse correctly interprets the finding as which of the following?
The client can read at 20 feet what a person with normal vision can read at
50 feet.
,Florida State College at Jacksonville
The clinical instructor is observing a student nurse perform eye exams.
Which technique by the student nurse demonstrates correct
understanding of testing the corneal light reflex?
The student compares the reflection of the light on the client's eye surface
A client tells the clinic nurse that she has sought care because she has
been experiencing excessive watering in her right eye. Which of the
following assessments should the nurse perform next?
Assess the nasolacrimal duct
A nurse is inspecting a client's eyelids and eyelashes. Which of the
following would the nurse document as a normal finding?
Lower eyelid touches the lower border of the iris
During the assessment of a client's internal eye structures, the nurse
notes a white optic disc. The nurse understands which of the following to
be the cause of this finding?
Optic nerve atrophy
, Florida State College at Jacksonville
A nurse in the emergency department assesses a client's pupillary
reaction and observes bilateral pinpoint pupils. The nurse interprets this
finding as suggesting which of the following?
Narcotic use
The nurse is assessing the client's eyes and vision. When performing the
confrontation test for peripheral vision, which of the following would the
nurse ask after covering one of the client's eyes?
Ask the client to state when they can see the nurse's finger enter their
visual field.
The nurse is testing for accommodation during a client's eye examination.
The nurse correctly performs the exam when they demonstrate which of
the following?
The nurse asks the client to focus on the penlight, and then asks the client
to follow the penlight to about 7 cm from the nose.
During a routing eye assessment of a 55-year-old client, the client states
they see "floaters" in their eyes. Which of the following actions by the
nurse would be most appropriate?
Document this as a normal physiological change with aging
NUR 3094C Health Assessment FINAL
EXAM Latest 2024.2025 FSCJ 100%
GRADED A+
The nurse is performing a neurological check on a client with a head injury
from a motor vehicle accident four hours ago. The nurse suspects the
client has developed increased intracranial pressure. Which of the
following would lead the nurse to suspect this diagnosis?
Fixed and dilated pupils
The nurse notes decorticate posturing in a client following a traumatic
brain injury. Which of the following assessments by the nurse would be
consistent with this posturing?
Flexion of the elbows
The nurse is performing hourly assessments of the client's level of
consciousness. During the assessment, the client remains unresponsive
after multiple attempts of the nurse calling their name. Which of the
following would the nurse perform next?
Gently shake the client's shoulders.
,Florida State College at Jacksonville
The nurse is assessing a client's cranial nerves XI (spinal accessory).
Which of the following would the nurse expect to observe?
The client is able to shrug shoulders against resistance
The nurse is preparing to assess the abstract reasoning of a client who
has a diagnosis of early stage Alzheimer disease. Which of the following
questions would be most appropriate for the nurse to ask?
"How are an apple and orange the same?"
As part of a mental status assessment, the nurse asks the client how they
would respond if they found a wallet lying on the sidewalk. This will allow
the nurse to assess which domain of mental status?
Judgment
The nurse records a client's visual acuity as 20/50 using the Snellen eye
chart. The nurse correctly interprets the finding as which of the following?
The client can read at 20 feet what a person with normal vision can read at
50 feet.
,Florida State College at Jacksonville
The clinical instructor is observing a student nurse perform eye exams.
Which technique by the student nurse demonstrates correct
understanding of testing the corneal light reflex?
The student compares the reflection of the light on the client's eye surface
A client tells the clinic nurse that she has sought care because she has
been experiencing excessive watering in her right eye. Which of the
following assessments should the nurse perform next?
Assess the nasolacrimal duct
A nurse is inspecting a client's eyelids and eyelashes. Which of the
following would the nurse document as a normal finding?
Lower eyelid touches the lower border of the iris
During the assessment of a client's internal eye structures, the nurse
notes a white optic disc. The nurse understands which of the following to
be the cause of this finding?
Optic nerve atrophy
, Florida State College at Jacksonville
A nurse in the emergency department assesses a client's pupillary
reaction and observes bilateral pinpoint pupils. The nurse interprets this
finding as suggesting which of the following?
Narcotic use
The nurse is assessing the client's eyes and vision. When performing the
confrontation test for peripheral vision, which of the following would the
nurse ask after covering one of the client's eyes?
Ask the client to state when they can see the nurse's finger enter their
visual field.
The nurse is testing for accommodation during a client's eye examination.
The nurse correctly performs the exam when they demonstrate which of
the following?
The nurse asks the client to focus on the penlight, and then asks the client
to follow the penlight to about 7 cm from the nose.
During a routing eye assessment of a 55-year-old client, the client states
they see "floaters" in their eyes. Which of the following actions by the
nurse would be most appropriate?
Document this as a normal physiological change with aging
