NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What are the components of a cultural response to a patient? ------- Correct Answers ----
---- the response should include modes of communication to include speech, space, and
body language, awareness of the the patients health beliefs, diet and nutritional
practice, and the nature of relationships with their family
How do you measure visual acuity and test CN II ------- Correct Answers -------- by
measuring distance, near vision , and peripheral vision
What is CN II? ------- Correct Answers -------- optic nerve
How do you measure distance vision for visual acuity? ------- Correct Answers -------- by
using a snellen chart and having the patient cover one eye and read the lowest line that
he can see clearly and then alternate eyes
How do you document distance vision? ------- Correct Answers -------- the numerator is
20 and the denominator is the distance at which the average eye can read the line.
How do you measure near vision? ------- Correct Answers -------- by using a rosenbaum
pocket screener and have the patient hold it about 14 inches from eyes and read the
smallest line possible with one eye and then the other
How do you measure peripheral vision? ------- Correct Answers -------- by using the
confrontation test. Have the patient sit directly across from you and look directly at you.
Have them cover their left eye and your cover your right eye. Then test nasal, temporal,
superior, and inferior fields. Have the patient tell you as soon as they see your finger in
each of those fields.
What may be some causes of abnormal results from the confrontation test? -------
Correct Answers -------- stroke, retinal detachment, optic neuropathy, pituitary tumor,
central retinal vascular occlusion
How would you perform an external examination of the eyes? ------- Correct Answers ---
- ----Systematically beginning with appendages and move inward
eyebrows
orbits/periorbital area
eyelids
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
,NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What is being assessed when looking at the patient's eyebrows? ------- Correct Answers
- -------size, extension beyond temporal canthus, texture of hair
If the eyebrows do not extend beyond the temporal canthus or are course what may be
the cause? ------- Correct Answers -------- hypothyroidism
What is being assessed when looking at the patient's orbits/periorbital area? -------
Correct Answers -------- edema, puffiness, sagging tissue below orbit
What can cause periorbital edema? ------- Correct Answers -------- thyroid disease,
allergies, or nephrotic syndrome (children)
What are xanthelasma? ------- Correct Answers --------yellowish deposits on the
periorbital tissue most often on the nasal side that represents a lipid metabolism
disorder
What is being assessed with looking at the patient's eyelids? ------- Correct Answers -----
--- have the patient close lids lightly to look for tremors
inspect ability of eyelids to close completely and open wide
check for flakiness, crusting, redness, or swelling
check eyelashes to make sure that they curve away from the eye
when eye is open the superior eyelid should cover a portion of the iris but not cover
pupil
What can be a cause of fasciculations of the eyelid when a patient lightly closes eye? ---
---- Correct Answers -------- hyperthyroidism
What is ptosis? ------- Correct Answers -------- when the upper eyelid covers more than
the top of the iris or pupil and indicates congenital weakness of levator muscle or
paresis of a branch of CN III
What is CN III ------- Correct Answers -------- oculomotor nerve
How do you document a finding of ptosis? ------- Correct Answers -------- by recording
the difference between the two eyelids in millimeters (the average lid is 2 mm below the
border of the cornea and sclera. average lower lid is at the lower limbus)
What is ectropion? ------- Correct Answers -------- it is when the lower eyelid turns away
from the eye and may result in excessive tearing because the tear collecting system
can't collect the secretions
What is entropion? ------- Correct Answers -------- it is when the eyelid turns toward the
globe which can cause corneal and conjunctival irritation and risk for secondary
infection
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
, NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What is a hordeolum? ------- Correct Answers -------- it is an acute suppurative
inflammation of an eyelash follicle which causes an erythematous or yellowish lump
What may be the cause of crusting along eyelashes? ------- Correct Answers --------
blepharitis caused by blockage of tiny oil glands or by bacteria, seborrhea, psoriasis,
rosacea, allergic response
What is lagophthalmos? ------- Correct Answers -------- it is when the eyelids to not meet
completely when closed and can be caused by thyroid disease, bell's palsy, aggressive
ptosis, blepharoplasty
When you palpate the eyes what are you assessing for? ------- Correct Answers --------
eyelids for nodules
orbit for intraocular pressure
If the patient complains of pain when you palpate the orbit what can be the cause? ------
- Correct Answers -------- scleritis, orbital cellulitis, cavernous sinus thrombosis
If the eye is very firm or resists palpation what does this indicate? ------- Correct
Answers -------- it can be a sign of severe glaucoma or retrobulbar tumor
How do you inspect the lower conjunctiva? ------- Correct Answers -------- have the
patient look up while you draw the lower eyelid down and note the translucency and
vascular pattern, erythema, exudate
How do you inspect the upper conjunctiva? ------- Correct Answers -------- this is only
done when there is a foreign object present. Evert the upper lid one a cotton swab
What can cause erythema or cobblestone appearance to conjunctiva? ------- Correct
Answers -------- allergic or infections conjunctivitis
What is a subconjunctival hemorrhage? ------- Correct Answers -------- it is seen as
bright red blood in a sharply defined area that is surrounded by healthy conjunctiva
which may occur spontaneously in pregnancy or labor
What is a pterygium? ------- Correct Answers -------- it is the abnormal growth of
conjunctiva tissue over the cornea and more common on the nasal side. This is more
common in persons exposed to UV light.
How do you examine the cornea for clarity? ------- Correct Answers -------- check for
clarity by shining a light tangentially on it. blood vessels should not be present
What is corneal arcus? ------- Correct Answers -------- it is lipid deposits in the periphery
of the cornea and common after age 60. If they present in persons less than 40 it may
indicate a lipid disorder
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What are the components of a cultural response to a patient? ------- Correct Answers ----
---- the response should include modes of communication to include speech, space, and
body language, awareness of the the patients health beliefs, diet and nutritional
practice, and the nature of relationships with their family
How do you measure visual acuity and test CN II ------- Correct Answers -------- by
measuring distance, near vision , and peripheral vision
What is CN II? ------- Correct Answers -------- optic nerve
How do you measure distance vision for visual acuity? ------- Correct Answers -------- by
using a snellen chart and having the patient cover one eye and read the lowest line that
he can see clearly and then alternate eyes
How do you document distance vision? ------- Correct Answers -------- the numerator is
20 and the denominator is the distance at which the average eye can read the line.
How do you measure near vision? ------- Correct Answers -------- by using a rosenbaum
pocket screener and have the patient hold it about 14 inches from eyes and read the
smallest line possible with one eye and then the other
How do you measure peripheral vision? ------- Correct Answers -------- by using the
confrontation test. Have the patient sit directly across from you and look directly at you.
Have them cover their left eye and your cover your right eye. Then test nasal, temporal,
superior, and inferior fields. Have the patient tell you as soon as they see your finger in
each of those fields.
What may be some causes of abnormal results from the confrontation test? -------
Correct Answers -------- stroke, retinal detachment, optic neuropathy, pituitary tumor,
central retinal vascular occlusion
How would you perform an external examination of the eyes? ------- Correct Answers ---
- ----Systematically beginning with appendages and move inward
eyebrows
orbits/periorbital area
eyelids
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
,NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What is being assessed when looking at the patient's eyebrows? ------- Correct Answers
- -------size, extension beyond temporal canthus, texture of hair
If the eyebrows do not extend beyond the temporal canthus or are course what may be
the cause? ------- Correct Answers -------- hypothyroidism
What is being assessed when looking at the patient's orbits/periorbital area? -------
Correct Answers -------- edema, puffiness, sagging tissue below orbit
What can cause periorbital edema? ------- Correct Answers -------- thyroid disease,
allergies, or nephrotic syndrome (children)
What are xanthelasma? ------- Correct Answers --------yellowish deposits on the
periorbital tissue most often on the nasal side that represents a lipid metabolism
disorder
What is being assessed with looking at the patient's eyelids? ------- Correct Answers -----
--- have the patient close lids lightly to look for tremors
inspect ability of eyelids to close completely and open wide
check for flakiness, crusting, redness, or swelling
check eyelashes to make sure that they curve away from the eye
when eye is open the superior eyelid should cover a portion of the iris but not cover
pupil
What can be a cause of fasciculations of the eyelid when a patient lightly closes eye? ---
---- Correct Answers -------- hyperthyroidism
What is ptosis? ------- Correct Answers -------- when the upper eyelid covers more than
the top of the iris or pupil and indicates congenital weakness of levator muscle or
paresis of a branch of CN III
What is CN III ------- Correct Answers -------- oculomotor nerve
How do you document a finding of ptosis? ------- Correct Answers -------- by recording
the difference between the two eyelids in millimeters (the average lid is 2 mm below the
border of the cornea and sclera. average lower lid is at the lower limbus)
What is ectropion? ------- Correct Answers -------- it is when the lower eyelid turns away
from the eye and may result in excessive tearing because the tear collecting system
can't collect the secretions
What is entropion? ------- Correct Answers -------- it is when the eyelid turns toward the
globe which can cause corneal and conjunctival irritation and risk for secondary
infection
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
, NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
What is a hordeolum? ------- Correct Answers -------- it is an acute suppurative
inflammation of an eyelash follicle which causes an erythematous or yellowish lump
What may be the cause of crusting along eyelashes? ------- Correct Answers --------
blepharitis caused by blockage of tiny oil glands or by bacteria, seborrhea, psoriasis,
rosacea, allergic response
What is lagophthalmos? ------- Correct Answers -------- it is when the eyelids to not meet
completely when closed and can be caused by thyroid disease, bell's palsy, aggressive
ptosis, blepharoplasty
When you palpate the eyes what are you assessing for? ------- Correct Answers --------
eyelids for nodules
orbit for intraocular pressure
If the patient complains of pain when you palpate the orbit what can be the cause? ------
- Correct Answers -------- scleritis, orbital cellulitis, cavernous sinus thrombosis
If the eye is very firm or resists palpation what does this indicate? ------- Correct
Answers -------- it can be a sign of severe glaucoma or retrobulbar tumor
How do you inspect the lower conjunctiva? ------- Correct Answers -------- have the
patient look up while you draw the lower eyelid down and note the translucency and
vascular pattern, erythema, exudate
How do you inspect the upper conjunctiva? ------- Correct Answers -------- this is only
done when there is a foreign object present. Evert the upper lid one a cotton swab
What can cause erythema or cobblestone appearance to conjunctiva? ------- Correct
Answers -------- allergic or infections conjunctivitis
What is a subconjunctival hemorrhage? ------- Correct Answers -------- it is seen as
bright red blood in a sharply defined area that is surrounded by healthy conjunctiva
which may occur spontaneously in pregnancy or labor
What is a pterygium? ------- Correct Answers -------- it is the abnormal growth of
conjunctiva tissue over the cornea and more common on the nasal side. This is more
common in persons exposed to UV light.
How do you examine the cornea for clarity? ------- Correct Answers -------- check for
clarity by shining a light tangentially on it. blood vessels should not be present
What is corneal arcus? ------- Correct Answers -------- it is lipid deposits in the periphery
of the cornea and common after age 60. If they present in persons less than 40 it may
indicate a lipid disorder
NURS 6512 - Advanced Health Assessment Exam 1 Study Guide
