and Correct Answers Rated A+ 2025
When testing for accommodation, what reaction would you expect to
see? - ANSWER>>CorrectD.
Pupils converge and constrict
Response Feedback:
You test for accommodation by asking the patient to focus on an
object (finger or pen, for example) as you move it towards the
patient's nose. You would expect the pupils to constrict and for eyes
to cross (convergence).
A nurse is admitting a client to the hospital. When reviewing the
client's medical record, the nurse notes that this client had abnormal
findings during the Weber test. What would the nurse know this
means? - ANSWER>>CorrectD.
The client has unilateral hearing loss
Response Feedback:
The whisper test evaluates loss of high-frequency sounds. The Weber
test helps to differentiate the cause of unilateral hearing loss. In the
Rinne test, use of a tuning fork helps the nurse determine if hearing is
equal in both ears and if there is either a conductive or a
sensorineural hearing loss by allowing the nurse to compare the
difference in bone conduction (BC) versus air conduction (AC).
Remember AC has less resistance than BC. Option D is a distracter
for this question.
A mother brings her 2-year-old child to the clinic stating that the child
is cross-eyed. What test would the nurse perform to test for
strabismus? - ANSWER>>CorrectB.
Corneal light reflex
,Response Feedback:
The corneal light reflex tests for strabismus. The cover test is for
presence and amount of ocular deviation. A low light level with no
direct light sources shining in the patient's eyes is ideal. At rest, the
extraocular muscles have very little activity. The assessment referred
to as cardinal fields of gaze allows nurses to detect muscle defects
that cause misalignment or uncoordinated eye movements. The static
test can help the nurse detect gross differences in all four quadrants
of the visual field. The Allen test tests a toddler's visual acuity.
What components of sound does the cochlea interpret? (Select all
that apply.) - ANSWER>>ANSWERs:
CorrectA.
Frequency
CorrectB.
Amplitude
Response Feedback:
The cochlea interprets two components of sound: amplitude (volume)
and frequency (pitch). The cochlea does not interpret tone, direction,
or decibel.
The nurse is caring for a client with an eye injury. The client asks
about the eye, and the nurse explains its structures and functions.
What would the nurse tell the client is the largest chamber of the eye?
- ANSWER>>CorrectA.
Vitreous
Response Feedback:
The interior eye has three chambers: anterior, posterior, and vitreous.
The anterior chamber is the space between the cornea in the front and
the iris and lens in the back. It contains aqueous humor, produced by
the ciliary body; the amount varies to maintain pressure in the eye.
,The posterior chamber starts behind the iris and goes to the lens. It is
also filled with aqueous humor that helps to nourish the cornea and
lens. The largest vitreous chamber is adjacent to the inner retinal
layer and lens. This chamber is filled with vitreous humor, which is
gel-like, holds the retina in place, and maintains the shape of the
eyeball. Corneal is a distracter for this question.
Student nurses are spending time in the laboratory learning the
proper use of an otoscope. What technique would these students
learn for best visualization of the tympanic membrane in an
adolescent? - ANSWER>>CorrectD.
Hold the ear at the helix and lift up and back
Response Feedback:
Hold the adolescent's ear at the helix and lift up and back to align the
canal for best visualization of the tympanic membrane. In children
younger than 3 years, the nurse would pull down and back to
visualize the tympanic membrane. The nurse always lifts from the
helix, not the auricle (pinna) and never from the tragus.
The nurse is assessing a client and notes dullness to percussion in
the lowest point of the abdomen. When rolling the client to the left,
the nurse notes that there is now dullness on the left side. This
indicates ascites, which can be caused by - ANSWER>>CorrectA.
Cirrhosis and nephrosis
Response Feedback:
Ascites is the accumulation of fluid in the abdomen. The fluid
descends with gravity, resulting in dullness to percussion in the
lowest point of the abdomen based on client position. Changing the
client's position should move the fluid shift to the most dependent
point. Ascites occurs in cirrhosis of the liver, congestive heart failure,
nephrosis, peritonitis, and metastatic neoplasms. The other options
are distracters to the question.
, When assessing the tympanic membrane, where would the nurse
expect to visualize the malleus? - ANSWER>>CorrectB.
Near the center
Response Feedback:
The tympanic membrane adheres through its concave shape to the
malleus near the center. The other options are distracters for the
question.
Which assessment techniques would a nurse use on the external ear?
(Select all that apply) - ANSWER>>Correct
Palpation
Correct
Inspection
The nurse is performing visual acuity testing on an older adult who
has fallen and fractured their femur. What finding would be
considered normal for this client? (Select all that apply.) -
ANSWER>>CorrectA.
Arcus senilis
CorrectD.
Decreased tear production
CorrectE.
Cataract
Response Feedback:
Findings related to aging include loss of adipose tissue in the orbit,
decreased tear production, and decreased pupillary response. Arcus
senilis, a gray/white circle that circumscribes the limbus and results
from the deposition of lipid, is a common cloudiness that appears
around the corneas of older adults. Cataracts are common in the