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EST VERSIONS (VERSION A, B AND C) NEWEST
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2024 ACTUAL EXAM 400 QUWESTIONS AND CO
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RRECT DETAILED ANSWERS WITH RATIONAL m m m m
ES (VERIFIED ANSWERS) | ALREADY GRADED
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A+
ATI HEALTH ASSESSMENT VERSION A
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A nurse is examining the eyes of a client who has complained of havin
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g a feeling of a foreign body in his eye. The nurse examines the thin, tr
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ansparent, continuous membrane that lines the inside of the eyelids an
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d covers most of the anterior eye. The nurse recognizes this membrane
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mas which of the following?
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a) Cornea
b) Conjunctiva
c) Retina
d) Sclera - ...ANSWER...Conjunctiva m m
Explanation:
The conjunctiva is a thin, transparent, continuous membrane that is di
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vided into two portions: a palpebral and a bulbar portion. The palpebr
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al conjunctiva lines the inside of the eyelids, and the bulbar conjunctiv
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a covers most of the anterior eye, merging with the cornea at the limb
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us. The innermost layer, the retina, extends only to the ciliary body an
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teriorly. It receives visual stimuli and sends them to the brain. The scle
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ra is a dense, protective, white covering that physically supports the in
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ternal structures of the eye. The transparent cornea (the "window of th
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e eye") permits the entrance of light, which passes through the lens to
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the retina. m
Which of the following findings should a doctor expect to note when a
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ssessing the six cardinal fields of gaze?
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a. The presence of nystagmus in all fields
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,b. Symmetrical corneal light reflex m m m
c. Presence of the red reflex m m m m
d. Smooth, coordinated movement of the eyes -
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m...ANSWER... EXPLANATION: Smooth, coordinated movement of m m m m m
mthe eyes- m
the six cardinal fields test eye movements and the muscle of the eye. n
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ormal findings include smooth, coordinated movement of the eyes wit
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h occasional mild nystagmus (jerking) in extreme lateral gaze. nystag
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mus in all six fields is an abnormal finding that requires further evalua
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tion. a symmetrical corneal light reflex is the expected response of the
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corneal light reflex test. the red reflex is assessed when using the opht
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halmoscope.
A nurse is presenting a class to a local community group about vision a
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nd eye health. As part of the presentation, the nurse explains how visu
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al perception occurs. Which of the following would the nurse include i
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n the explanation?
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a) It primarily involves the lens of the eye.
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b) It allows the eyes to focus on near objects.
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c) It begins with light rays striking the retina.
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d) It refers to a client's subjective appraisal of his or her vision. -
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...ANSWER...It begins with light rays striking the retina. m m m m m m m
Explanation:
Visual perception occurs as light rays strike the retina, where they are t
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ransformed into nerve impulses, conducted to the brain through the op
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tic nerve, and interpreted. The lens does not contribute directly to visu
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al perception. Accommodation is the process that allows the eyes to fo
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cus on near objects.
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The nurse is conducting a visual examination. Which of these stateme
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nts regarding visual pathways and visual fields is true?
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a. The right side of the brain interprets the vision for the right eye.
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b. The image formed on the retina is upside down and reversed from
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mits actual appearance in the outside world.
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c. Light rays are refracted through the transparent media of the eye
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mbefore striking the pupil. m m m
,d. Light impulses are conducted through the optic nerve to the
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mtemporal lobes of the brain. - ...ANSWER...B
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RATIONALE: The image formed on the retina is upside down and r m m m m m m m m m m m
eversed from its actual appearance in the outside world. The light ray
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s are refracted through the transparent media of the eye before strikin
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g the retina, and the nerve impulses are conducted through the optic n
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erve tract to the visual cortex of the occipital lobe of the brain. The le
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ft side of the brain interprets vision for the right eye.
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A patient has a normal pupillary light reflex. The nurse recognizes th
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at this reflex indicates that:
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a. The eyes converge to focus on the light.
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b. Light is reflected at the same spot in both eyes.
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c. The eye focuses the image in the center of the pupil. d.Constri
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ction of both pupils occurs in response to bright light. -
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...ANSWER...D
EXPLANATION: The pupillary light reflex is the normal constrictio m m m m m m m m
n of the pupils when bright light shines on the retina. The other respon
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ses are not correct.
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In using the ophthalmoscope to assess a patient's eyes, the nurse notice
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s a red glow in the patient's pupils. On the basis of this finding, the nur
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se would:
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a. Suspect that an opacity is present in the lens or cornea.
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b. Check the light source of the ophthalmoscope to verify that it is
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mfunctioning.
c. Consider the red glow a normal reflection of the ophthalmoscope
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mlight off the inner retina.
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d. Continue with the ophthalmoscopic examination, and refer the
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mpatient for further evaluation. - ...ANSWER...C
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EXPLANATION: The red glow filling the person's pupil is the red re m m m m m m m m m m m
flex and is a normal finding caused by the reflection of the ophthalmo
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scope light off the inner retina. The other responses are not correct.
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The nurse is examining a patient's retina with an ophthalmoscope. Whi
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ch finding is considered normal?
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, a. Optic disc that is a yellow-orange color
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b. Optic disc margins that are blurred around the edges
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c. Presence of pigmented crescents in the macular area
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d. Presence of the macula located on the nasal side of the retina -
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...ANSWER...A
RATIONALE: The optic disc is located on the nasal side of the retin m m m m m m m m m m m m
a. Its color is a creamy yellow-
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orange to a pink, and the edges are distinct and sharply demarcated, n
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ot blurred. A pigmented crescent is black and is due to the accumulati
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on of pigment in the choroid.
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When performing the corneal light reflex assessment, the nurse notes t
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hat the light is reflected at 2 o'clock in each eye. The nurse should:
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a. Consider this a normal finding. m m m m
b. Refer the individual for further evaluation.
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c. Document this finding as an asymmetric light reflex.
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d. Perform the confrontation test to validate the findings. -
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...ANSWER...A
EXPLANATION: Reflection of the light on the corneas should be in m m m m m m m m m m m
exactly the same spot on each eye, or symmetric. If asymmetry is note
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d, then the nurse should administer the cover test.
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The nurse is performing an eye-
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screening clinic at a daycare center. When examining a 2-year-
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old child, the nurse suspects that the child has a "lazy eye" and should:
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a. Examine the external structures of the eye.
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b. Assess visual acuity with the Snellen eye chart.
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c. Assess the child's visual fields with the confrontation test.
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d. Test for strabismus by performing the corneal light reflex test. -
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...ANSWER...D
Testing for strabismus is done by performing the corneal light reflex t
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est and the cover test. The Snellen eye chart and confrontation test ar
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e not used to test for strabismus.
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Which of the following terms describes involuntary, jerking, rhythmic
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movements of the eyes? m m m
a. diplopia
b. exophthalmos