Health Assessment Final Exam
Graded A+
The nurse is performing a neurological check on a client with a head injury from a motor vehicle
accident four hours ago. The nurse suspects the client has developed increased intracranial pressure.
Which of the following would lead the nurse to suspect this diagnosis? - Answer Fixed and dilated pupils
The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the
following assessments by the nurse would be consistent with this posturing? - Answer Flexion of the
elbows
The nurse is performing hourly assessments of the client's level of consciousness. During the
assessment, the client remains unresponsive after multiple attempts of the nurse calling their name.
Which of the following would the nurse perform next? - Answer Gently shake the client's shoulders.
The nurse is assessing a client's cranial nerves XI (spinal accessory). Which of the following would the
nurse expect to observe? - Answer The client is able to shrug shoulders against resistance
The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage
Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask? -
Answer "How are an apple and orange the same?"
As part of a mental status assessment, the nurse asks the client how they would respond if they found a
wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status? - Answer
Judgment
The nurse records a client's visual acuity as 20/50 using the Snellen eye chart. The nurse correctly
interprets the finding as which of the following? - Answer The client can read at 20 feet what a person
with normal vision can read at 50 feet.
The clinical instructor is observing a student nurse perform eye exams. Which technique by the student
nurse demonstrates correct understanding of testing the corneal light reflex? - Answer The student
compares the reflection of the light on the client's eye surface
, A client tells the clinic nurse that she has sought care because she has been experiencing excessive
watering in her right eye. Which of the following assessments should the nurse perform next? - Answer
Assess the nasolacrimal duct
A nurse is inspecting a client's eyelids and eyelashes. Which of the following would the nurse document
as a normal finding? - Answer Lower eyelid touches the lower border of the iris
During the assessment of a client's internal eye structures, the nurse notes a white optic disc. The nurse
understands which of the following to be the cause of this finding? - Answer Optic nerve atrophy
A nurse in the emergency department assesses a client's pupillary reaction and observes bilateral
pinpoint pupils. The nurse interprets this finding as suggesting which of the following? - Answer Narcotic
use
The nurse is assessing the client's eyes and vision. When performing the confrontation test for
peripheral vision, which of the following would the nurse ask after covering one of the client's eyes? -
Answer Ask the client to state when they can see the nurse's finger enter their visual field.
The nurse is testing for accommodation during a client's eye examination. The nurse correctly performs
the exam when they demonstrate which of the following? - Answer The nurse asks the client to focus on
the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.
During a routing eye assessment of a 55-year-old client, the client states they see "floaters" in their eyes.
Which of the following actions by the nurse would be most appropriate? - Answer Document this as a
normal physiological change with aging
The nurse is performing the positions test on a client. During the assessment, the nurse notes oscillating
movements of the client's eyes. The nurse would correctly document this finding as which of the
following? - Answer Nystagmus
The nurse is assessing the external eye structures of an elderly client. Which of the following age-related
findings would the nurse anticipate observing? - Answer Arcus senilis
Graded A+
The nurse is performing a neurological check on a client with a head injury from a motor vehicle
accident four hours ago. The nurse suspects the client has developed increased intracranial pressure.
Which of the following would lead the nurse to suspect this diagnosis? - Answer Fixed and dilated pupils
The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the
following assessments by the nurse would be consistent with this posturing? - Answer Flexion of the
elbows
The nurse is performing hourly assessments of the client's level of consciousness. During the
assessment, the client remains unresponsive after multiple attempts of the nurse calling their name.
Which of the following would the nurse perform next? - Answer Gently shake the client's shoulders.
The nurse is assessing a client's cranial nerves XI (spinal accessory). Which of the following would the
nurse expect to observe? - Answer The client is able to shrug shoulders against resistance
The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage
Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask? -
Answer "How are an apple and orange the same?"
As part of a mental status assessment, the nurse asks the client how they would respond if they found a
wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status? - Answer
Judgment
The nurse records a client's visual acuity as 20/50 using the Snellen eye chart. The nurse correctly
interprets the finding as which of the following? - Answer The client can read at 20 feet what a person
with normal vision can read at 50 feet.
The clinical instructor is observing a student nurse perform eye exams. Which technique by the student
nurse demonstrates correct understanding of testing the corneal light reflex? - Answer The student
compares the reflection of the light on the client's eye surface
, A client tells the clinic nurse that she has sought care because she has been experiencing excessive
watering in her right eye. Which of the following assessments should the nurse perform next? - Answer
Assess the nasolacrimal duct
A nurse is inspecting a client's eyelids and eyelashes. Which of the following would the nurse document
as a normal finding? - Answer Lower eyelid touches the lower border of the iris
During the assessment of a client's internal eye structures, the nurse notes a white optic disc. The nurse
understands which of the following to be the cause of this finding? - Answer Optic nerve atrophy
A nurse in the emergency department assesses a client's pupillary reaction and observes bilateral
pinpoint pupils. The nurse interprets this finding as suggesting which of the following? - Answer Narcotic
use
The nurse is assessing the client's eyes and vision. When performing the confrontation test for
peripheral vision, which of the following would the nurse ask after covering one of the client's eyes? -
Answer Ask the client to state when they can see the nurse's finger enter their visual field.
The nurse is testing for accommodation during a client's eye examination. The nurse correctly performs
the exam when they demonstrate which of the following? - Answer The nurse asks the client to focus on
the penlight, and then asks the client to follow the penlight to about 7 cm from the nose.
During a routing eye assessment of a 55-year-old client, the client states they see "floaters" in their eyes.
Which of the following actions by the nurse would be most appropriate? - Answer Document this as a
normal physiological change with aging
The nurse is performing the positions test on a client. During the assessment, the nurse notes oscillating
movements of the client's eyes. The nurse would correctly document this finding as which of the
following? - Answer Nystagmus
The nurse is assessing the external eye structures of an elderly client. Which of the following age-related
findings would the nurse anticipate observing? - Answer Arcus senilis
