NURS 380 - Assessment and Health Promotion Final Exam
Questions with Answers Latest Update
When using the Snellen chart, what does a vision evaluation of 20/50 mean?
The patient has difficulty seeing far objects clearly.
The patient can read at 50 feet what most people can read at 20 feet
The patient can read at 20 feet what most people can read at 50 feet.
Both A and B. - Correct Answer ANS:
B. Both A and B
20/50 on the Snellen chart means that the patient has difficulty seeing far objects
clearly and can read at 20 feet what most people can read at 50 feet. 20/50 on the
Snellen chart does not mean that the patient can read at 50 feet what most people
can read at 20 feet.
What does full movement of the eyes in the six cardinal fields of gaze reflect?
Proper functioning of the extraocular muscles
Proper functioning of the olfactory and optic nerves
Proper functioning of the oculomotor, trochlear, and abducens nerves
Both A and C - Correct Answer ANS:
Both B and C
Proper functioning of the oculomotor, trochlear, and abducens nerves plus proper
functioning of the extraocular muscles is reflected by full movement of the eyes in
the six cardinal fields of gaze. Proper functioning of the olfactory and optic nerves is
reflected by an accurate sense of smell and accurate vision on the Snellen and
Rosenbaum charts, not the movement of the eyes in the six cardinal fields of gaze.
What term refers to the constriction of the pupils when a patient focuses on an object
held about 10 centimeters from the nose?
Ptosis
Peripheral vision
Glaucoma
, Accommodation - Correct Answer ANS:
Accommodation
Accommodation is the correct term for constriction of the pupils when focusing on an
object held about 10 centimeters from the nose. Ptosis is drooping of the upper
eyelid, not constriction of the pupils. Glaucoma is a condition that causes damage to
the eye's optic nerve, not constriction of the pupils when focusing on an object 10
centimeters from the nose. Peripheral vision is the part of vision that occurs outside
the center of the gaze, not constriction of the pupils.
Which of the following are risk factors for glaucoma?
Age over 40 years
All of the above
Diabetes
High Blood Pressure - Correct Answer ANS:
All of the above
All three answers, age over 40 years, diabetes, and high blood pressure are risk
factors for glaucoma.
When examining the eyes, which of the following is an expected finding?
Reddened conjunctivae
Periorbital edema
Equal pupils
Crusted eyelashes - Correct Answer ANS:
Equal Pupils
Equal pupils are an expected finding during an eye exam. Reddened conjunctivae
are not an expected finding during an eye exam. Crusted eyelashes are not an
expected finding during an eye exam. Periorbital edema is not an expected finding
during an eye exam.
Which test or tests assess accuracy of movement?
Finger-to-finger test
All of the above
, Finger-to-nose test
Heel-to-shin test - Correct Answer ANS:
B. All of the above
All of the above tests can be used to assess accuracy of movement. The finger-to-
finger test is used to assess accuracy of movement. The patient's movements
should be rapid, smooth, and accurate with no past pointing. The finger-to-nose test
is used to assess accuracy of movement. The patient's movements should be rapid,
smooth, and accurate, even with increasing speed. The heel-to-shin test is used to
assess accuracy of movement. The patient should move his heel in a straight line
without deviations to the side.
What should the nurse do if a patient displays staggering or loss of balance during
the Romberg test?
Give the patient a gentle push to further assess balance.
Have the patient hop on one foot.
Delay other balance tests.
Have the patient stand on one foot with the eyes closed. - Correct Answer
ANS:
Delay other balance tests
If a patient has staggering or loss of balance with the Romberg test, delay other
balance tests. If a patient has staggering or loss of balance with the Romberg test,
delay other balance tests; do not give the patient a gentle push to further assess
balance. If a patient has staggering or loss of balance with the Romberg test, delay
other balance tests; do not have the patient stand on one foot with eyes closed. If a
patient has staggering or loss of balance with the Romberg test, delay other balance
tests; do not have the patient hop on one foot.
How would you assess sensitivity to superficial pain?
Touch the patient with the sharp side of a broken tongue blade.
Both A and D.
Have the patient keep his or her eyes open.
Allow 2 seconds between stimuli. - Correct Answer ANS:
B. Both A and D
, Touching the patient with the sharp side of a broken tongue blade and allowing 2
seconds between stimuli are both part of a thorough assessment for superficial pain
sensation. Assessment of superficial pain can be done by touching the patient with
the sharp side of a broken tongue blade. With the patient's eyes closed, ask the
patient to identify if the sensation is dull or sharp. Assessment of superficial pain is
performed with the patient's eyes closed. For assessment of superficial pain,
randomly apply the sharp and dull stimuli, allowing 2 seconds between stimuli to
avoid a summative effect.
A deep tendon reflex with a normal response is scored as:
0
3+
1+
2+ - Correct Answer ANS:
2+
2+ is considered an active or expected response for deep tendon reflex; this is a
normal response. 0 indicates no response for deep tendon reflex; this is an
abnormal response. 1+ indicates a sluggish or diminished response for deep tendon
reflex; this is an abnormal response. 3+ is a brisker-than-expected or slightly
hyperactive response; this is an abnormal response.
Which of the following tips will assist with eliciting the patellar and Achilles deep
tendon reflexes?
Have the patient sit with his or her feet flat on the floor.
Strike the knee above the patella.
Have the patient focus on pulling his or her clasped hands apart.
Have the patient flex his or her knees at a 45-degree angle. - Correct
Answer ANS:
C. Have the patient focus on pulling his or her clasped hands apart.
With the patient in a seated position, have him or her focus on pulling his or her
clasped hands apart; this will take focus away from the test of deep tendon reflexes.
The patient should sit so that the upper legs are supported and the lower legs hang
loosely. The patient should flex his or her knees at a 90-degree angle. Strike the
knee just below the patella.
Questions with Answers Latest Update
When using the Snellen chart, what does a vision evaluation of 20/50 mean?
The patient has difficulty seeing far objects clearly.
The patient can read at 50 feet what most people can read at 20 feet
The patient can read at 20 feet what most people can read at 50 feet.
Both A and B. - Correct Answer ANS:
B. Both A and B
20/50 on the Snellen chart means that the patient has difficulty seeing far objects
clearly and can read at 20 feet what most people can read at 50 feet. 20/50 on the
Snellen chart does not mean that the patient can read at 50 feet what most people
can read at 20 feet.
What does full movement of the eyes in the six cardinal fields of gaze reflect?
Proper functioning of the extraocular muscles
Proper functioning of the olfactory and optic nerves
Proper functioning of the oculomotor, trochlear, and abducens nerves
Both A and C - Correct Answer ANS:
Both B and C
Proper functioning of the oculomotor, trochlear, and abducens nerves plus proper
functioning of the extraocular muscles is reflected by full movement of the eyes in
the six cardinal fields of gaze. Proper functioning of the olfactory and optic nerves is
reflected by an accurate sense of smell and accurate vision on the Snellen and
Rosenbaum charts, not the movement of the eyes in the six cardinal fields of gaze.
What term refers to the constriction of the pupils when a patient focuses on an object
held about 10 centimeters from the nose?
Ptosis
Peripheral vision
Glaucoma
, Accommodation - Correct Answer ANS:
Accommodation
Accommodation is the correct term for constriction of the pupils when focusing on an
object held about 10 centimeters from the nose. Ptosis is drooping of the upper
eyelid, not constriction of the pupils. Glaucoma is a condition that causes damage to
the eye's optic nerve, not constriction of the pupils when focusing on an object 10
centimeters from the nose. Peripheral vision is the part of vision that occurs outside
the center of the gaze, not constriction of the pupils.
Which of the following are risk factors for glaucoma?
Age over 40 years
All of the above
Diabetes
High Blood Pressure - Correct Answer ANS:
All of the above
All three answers, age over 40 years, diabetes, and high blood pressure are risk
factors for glaucoma.
When examining the eyes, which of the following is an expected finding?
Reddened conjunctivae
Periorbital edema
Equal pupils
Crusted eyelashes - Correct Answer ANS:
Equal Pupils
Equal pupils are an expected finding during an eye exam. Reddened conjunctivae
are not an expected finding during an eye exam. Crusted eyelashes are not an
expected finding during an eye exam. Periorbital edema is not an expected finding
during an eye exam.
Which test or tests assess accuracy of movement?
Finger-to-finger test
All of the above
, Finger-to-nose test
Heel-to-shin test - Correct Answer ANS:
B. All of the above
All of the above tests can be used to assess accuracy of movement. The finger-to-
finger test is used to assess accuracy of movement. The patient's movements
should be rapid, smooth, and accurate with no past pointing. The finger-to-nose test
is used to assess accuracy of movement. The patient's movements should be rapid,
smooth, and accurate, even with increasing speed. The heel-to-shin test is used to
assess accuracy of movement. The patient should move his heel in a straight line
without deviations to the side.
What should the nurse do if a patient displays staggering or loss of balance during
the Romberg test?
Give the patient a gentle push to further assess balance.
Have the patient hop on one foot.
Delay other balance tests.
Have the patient stand on one foot with the eyes closed. - Correct Answer
ANS:
Delay other balance tests
If a patient has staggering or loss of balance with the Romberg test, delay other
balance tests. If a patient has staggering or loss of balance with the Romberg test,
delay other balance tests; do not give the patient a gentle push to further assess
balance. If a patient has staggering or loss of balance with the Romberg test, delay
other balance tests; do not have the patient stand on one foot with eyes closed. If a
patient has staggering or loss of balance with the Romberg test, delay other balance
tests; do not have the patient hop on one foot.
How would you assess sensitivity to superficial pain?
Touch the patient with the sharp side of a broken tongue blade.
Both A and D.
Have the patient keep his or her eyes open.
Allow 2 seconds between stimuli. - Correct Answer ANS:
B. Both A and D
, Touching the patient with the sharp side of a broken tongue blade and allowing 2
seconds between stimuli are both part of a thorough assessment for superficial pain
sensation. Assessment of superficial pain can be done by touching the patient with
the sharp side of a broken tongue blade. With the patient's eyes closed, ask the
patient to identify if the sensation is dull or sharp. Assessment of superficial pain is
performed with the patient's eyes closed. For assessment of superficial pain,
randomly apply the sharp and dull stimuli, allowing 2 seconds between stimuli to
avoid a summative effect.
A deep tendon reflex with a normal response is scored as:
0
3+
1+
2+ - Correct Answer ANS:
2+
2+ is considered an active or expected response for deep tendon reflex; this is a
normal response. 0 indicates no response for deep tendon reflex; this is an
abnormal response. 1+ indicates a sluggish or diminished response for deep tendon
reflex; this is an abnormal response. 3+ is a brisker-than-expected or slightly
hyperactive response; this is an abnormal response.
Which of the following tips will assist with eliciting the patellar and Achilles deep
tendon reflexes?
Have the patient sit with his or her feet flat on the floor.
Strike the knee above the patella.
Have the patient focus on pulling his or her clasped hands apart.
Have the patient flex his or her knees at a 45-degree angle. - Correct
Answer ANS:
C. Have the patient focus on pulling his or her clasped hands apart.
With the patient in a seated position, have him or her focus on pulling his or her
clasped hands apart; this will take focus away from the test of deep tendon reflexes.
The patient should sit so that the upper legs are supported and the lower legs hang
loosely. The patient should flex his or her knees at a 90-degree angle. Strike the
knee just below the patella.
