NUR 210 - Final || with Error-free Answers.
What is the normal response to the accommodation test?
a. Convergence of the axis of the eyes and constriction of the pupils
b. A direct light reflex and consensual light reflex
c. Conjugate movement of the eyes in all 6 cardinal positions of gaze
d. Symmetrical dilation of bilateral pupils correct answers a. Convergence of the axis of the eyes
and constriction of the pupils
How will the nurse assess the peripheral vision of an adult patient who was admitted to the
hospital with a possible stroke?
a. Perform the Snellen alphabet test
b. Perform the diagnostic positions test
c. Perform the corneal light reflex test
d. Perform the confrontation test correct answers d. Perform the confrontation test
Which cranial nerves are being tested when the nurse has a patient perform the diagnostic
positions test?
a. Cranial nerves III, IV and VI
b. Cranial nerves II, III and IV
c. Cranial nerves IV, V and VI
d. Cranial nerves III, IV and V correct answers a. Cranial nerves III, IV and VI
What is the best nursing response when asymmetric corneal light reflex is observed in a 3 year
old child?
a. Look for other signs of Bell's palsy
,b. Refer the patient to the appropriate specialist due to strabismus
c. No action is needed, because this is a normal finding in children under the age of 6
d. Notify the physician of cranial nerve II dysfunction correct answers b. Refer the patient to the
appropriate specialist due to strabismus
What is the nursing priority for an African-American patient with small brown macules on the
sclera?
a. Refer the patient to an ophthalmologist for further testing.
b. Notify the patient that he may have liver disease and should have it checked.
c. Proceed with the examination as planned because this is a normal finding.
d. Instruct the patient to wear sunglasses when outdoors to prevent further macule formation.
correct answers c. Proceed with the examination as planned because this is a normal finding.
How will the nurse document assessment of the eyes in an adult patient that has drooping of the
left eye lid with a smaller distance between the upper and lower lids on the left?
a. Exophthalmos of the right eye
b. Ptosis of the left eye lid
c. Anisocoria of the left eye lid
d. Nystagmus of the left eye correct answers b. Ptosis of the left eye lid
What is the priority nursing intervention when the nurse observes that an elderly patient cannot
move the eyes past the midline to the left when performing the diagnostic positions test?
a. Perform the Snellen eye test and pupillary light reflex to further test cranial nerve II.
b. Document dysfunction of cranial nerves II and III and proceed with the assessment.
c. Continue the assessment, because this is a normal finding in elderly patients.
,d. Refer patient for further testing due to possible dysfunction of cranial nerves III, IV and VI.
correct answers d. Refer patient for further testing due to possible dysfunction of cranial nerves
III, IV and VI.
What type of vision loss does the nurse expect in a patient that has experienced an infarct
involving the left cerebral optic tract (left hemispheric stroke)?
a. Visual field loss in the right temporal and left nasal fields
b. Visual field loss in the right nasal and left nasal fields
c. Visual field loss in the right temporal and left temporal fields
d. Visual field loss in right nasal and left temporal fields correct answers a. Visual field loss in
the right temporal and left nasal fields
The mother of a 2-year-old is concerned because her son has had three ear infections in the past
year. What would be an appropriate response by the nurse?
a.
"It is unusual for a small child to have frequent ear infections unless something else is wrong."
b.
"We need to check the immune system of your son to determine why he is having so many ear
infections."
c.
"Ear infections are not uncommon in infants and toddlers because they tend to have more
cerumen in the external ear."
d.
"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for
infections to develop more easily." correct answers d. "Your son's eustachian tube is shorter and
wider than yours because of his age, which allows for infections to develop more easily."
, How does the nurse interpret the following information: an adult patient states that he has the
sensation that everything around him is spinning?
a.
Dizziness caused by cranial nerve VIII dysfunction
b.
Vertigo and the middle ear is responsible for this sensation
c.
Near syncope caused by dysfunction of the organ of Corti
d.
Vertigo and the inner ear is responsible for this sensation correct answers d. Vertigo and the inner
ear is responsible for this sensation
What is the nursing priority when the family of a 2 year old child states that he cannot produce
any intelligible speech and is inattentive in conversation?
a.
Refer the patient to the appropriate specialist due to possible hearing loss
b.
Note the placement of the ears, to assess for possible Down syndrome.
c.
Reduce background noise and speak in a lower tone to the child.
d.
Explain to the family that most children do not say any words clearly until age 3. correct answers
a.
Refer the patient to the appropriate specialist due to possible hearing loss
How does the nurse interpret the following assessment findings; painful movement of the pinna
and tragus with redness and swelling of the pinna and canal?
What is the normal response to the accommodation test?
a. Convergence of the axis of the eyes and constriction of the pupils
b. A direct light reflex and consensual light reflex
c. Conjugate movement of the eyes in all 6 cardinal positions of gaze
d. Symmetrical dilation of bilateral pupils correct answers a. Convergence of the axis of the eyes
and constriction of the pupils
How will the nurse assess the peripheral vision of an adult patient who was admitted to the
hospital with a possible stroke?
a. Perform the Snellen alphabet test
b. Perform the diagnostic positions test
c. Perform the corneal light reflex test
d. Perform the confrontation test correct answers d. Perform the confrontation test
Which cranial nerves are being tested when the nurse has a patient perform the diagnostic
positions test?
a. Cranial nerves III, IV and VI
b. Cranial nerves II, III and IV
c. Cranial nerves IV, V and VI
d. Cranial nerves III, IV and V correct answers a. Cranial nerves III, IV and VI
What is the best nursing response when asymmetric corneal light reflex is observed in a 3 year
old child?
a. Look for other signs of Bell's palsy
,b. Refer the patient to the appropriate specialist due to strabismus
c. No action is needed, because this is a normal finding in children under the age of 6
d. Notify the physician of cranial nerve II dysfunction correct answers b. Refer the patient to the
appropriate specialist due to strabismus
What is the nursing priority for an African-American patient with small brown macules on the
sclera?
a. Refer the patient to an ophthalmologist for further testing.
b. Notify the patient that he may have liver disease and should have it checked.
c. Proceed with the examination as planned because this is a normal finding.
d. Instruct the patient to wear sunglasses when outdoors to prevent further macule formation.
correct answers c. Proceed with the examination as planned because this is a normal finding.
How will the nurse document assessment of the eyes in an adult patient that has drooping of the
left eye lid with a smaller distance between the upper and lower lids on the left?
a. Exophthalmos of the right eye
b. Ptosis of the left eye lid
c. Anisocoria of the left eye lid
d. Nystagmus of the left eye correct answers b. Ptosis of the left eye lid
What is the priority nursing intervention when the nurse observes that an elderly patient cannot
move the eyes past the midline to the left when performing the diagnostic positions test?
a. Perform the Snellen eye test and pupillary light reflex to further test cranial nerve II.
b. Document dysfunction of cranial nerves II and III and proceed with the assessment.
c. Continue the assessment, because this is a normal finding in elderly patients.
,d. Refer patient for further testing due to possible dysfunction of cranial nerves III, IV and VI.
correct answers d. Refer patient for further testing due to possible dysfunction of cranial nerves
III, IV and VI.
What type of vision loss does the nurse expect in a patient that has experienced an infarct
involving the left cerebral optic tract (left hemispheric stroke)?
a. Visual field loss in the right temporal and left nasal fields
b. Visual field loss in the right nasal and left nasal fields
c. Visual field loss in the right temporal and left temporal fields
d. Visual field loss in right nasal and left temporal fields correct answers a. Visual field loss in
the right temporal and left nasal fields
The mother of a 2-year-old is concerned because her son has had three ear infections in the past
year. What would be an appropriate response by the nurse?
a.
"It is unusual for a small child to have frequent ear infections unless something else is wrong."
b.
"We need to check the immune system of your son to determine why he is having so many ear
infections."
c.
"Ear infections are not uncommon in infants and toddlers because they tend to have more
cerumen in the external ear."
d.
"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for
infections to develop more easily." correct answers d. "Your son's eustachian tube is shorter and
wider than yours because of his age, which allows for infections to develop more easily."
, How does the nurse interpret the following information: an adult patient states that he has the
sensation that everything around him is spinning?
a.
Dizziness caused by cranial nerve VIII dysfunction
b.
Vertigo and the middle ear is responsible for this sensation
c.
Near syncope caused by dysfunction of the organ of Corti
d.
Vertigo and the inner ear is responsible for this sensation correct answers d. Vertigo and the inner
ear is responsible for this sensation
What is the nursing priority when the family of a 2 year old child states that he cannot produce
any intelligible speech and is inattentive in conversation?
a.
Refer the patient to the appropriate specialist due to possible hearing loss
b.
Note the placement of the ears, to assess for possible Down syndrome.
c.
Reduce background noise and speak in a lower tone to the child.
d.
Explain to the family that most children do not say any words clearly until age 3. correct answers
a.
Refer the patient to the appropriate specialist due to possible hearing loss
How does the nurse interpret the following assessment findings; painful movement of the pinna
and tragus with redness and swelling of the pinna and canal?
