NR 302 Health Assessment I Unit 4 Pre-test

NR 302 Health Assessment I Unit 4 Pre-test Answer the following questions. Give rationales for each question asked. Upload test questions and rationales to the submission tab under the course shell. Questions will be graded for accuracy. Each question along with the rationale will be worth 1 point, for a total of 15 points possible. Late policy applies. Chapter 14 1. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI. Rationale: In our textbook on page 277, it states that the extraocular muscles are controlled by cranial nerve III, IV, and VI. Each of these ocular muscles is coordinated with one in the other eye making the muscles in the eye move together, which is called conjugate movement (pg. 277). 2. The nurse is testing a patient’s visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light Rationale: As stated in our book on page 277, accommodation is the adaptation of the eye for near vision. It is talented by increasing the curvature of the lens through the muscle of the ciliary body. The eye lens cannot be observed directly, the components of accommodation that can be observed are convergence, which means motion toward, of the axes of the eyeballs and pupillary constriction (pg. 277). 3. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures Rationale: Reading this chapter, I learned that the retinal background in any patient will be a slightly darker color and it will be where the sharpest vision in the patient is apparent. The structures that make up the retinal background are the macula, fovea centralis and retinal vessels. To be specific the macula is what has a darker pigmentation because it is on the temporal side of the fundus (pg. 278). 4. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers. Rationale: Our textbook describes floaters as something that is common in people over the age of 50 and can be the result of condensed vitreous fibers. Floaters can develop more intensely in those who are suffering from retinal detachment. In most cases these are considered a normal finding (pg. 280-281). 5. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient’s ability to read newsprint at a distance of 12 to 14 inches. Rationale: Chapter 15 of our textbook says the most common used test for visual acuity is the Snellen chart. Place the patient 20 feet away, and they are to read the letters that they see on the sheet using an opaque card to block one eye. This test will help the nurse identify if the patient needs glasses or not (pg. 283). 6. A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: