Comprehensive Nursing Assessment and
Clinical Reasoning Guide: In-Depth Questions,
Answers, and Rationales Covering Visual and
Auditory Systems, Oral and Nasal Health,
Respiratory and Cardiac Function, and Breast
Examination Across the Lifespan Exam
Questions Verified and Provided with A+
Graded Rationales Latest Updated 2026
The nurse is conducting a visual examination. Which of these statements regarding visual
pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance in
the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
b. The image formed on the retina is upside down and reversed from its actual appearance in
the outside world.
The nurse is testing a patients visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
a. Pupillary constriction when looking at a near object
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
d. Constriction of both pupils occurs in response to bright light.
,A mother asks when her newborn infants eyesight will be developed. The nurse should reply:
a. Vision is not totally developed until 2 years of age.
b. Infants develop the ability to focus on an object at approximately 8 months of age.
c. By approximately 3 months of age, infants develop more coordinated eye movements and can
fixate on an object.
d. Most infants have uncoordinated eye movements for the first year of life.
c. By approximately 3 months of age, infants develop more coordinated eye movements and can
fixate on an object.
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
b. Loss of lens elasticity
11. Which of these assessment findings would the nurse expect to see when examining the eyes
of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures
b. Dark retinal background
An ethnically based variability in the color of the iris and in retinal pigmentation exists, with
darker irides having darker retinas behind them.
12. A 52-year-old patient describes the presence of occasional floaters or spots moving in front
of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse
proceed?
,a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.
c. Use the Snellen chart positioned 20 feet away from the patient.
A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets
these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
The top number indicates the distance the person is standing from the chart; the denominator
gives the distance at which a normal eye can see.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take
which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in front of his
or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart
again.
d. Shorten the distance between the patient and the chart until the letters are seen, and record
that distance.
d. Shorten the distance between the patient and the chart until the letters are seen, and record
that distance.
A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that
the patient:
a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
a. Has poor vision.
, The nurse is performing the diagnostic positions test. Normal findings would be which of these
results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
b. Parallel movement of both eyes
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis
of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individuals near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
c. Observe the distance between the palpebral fissures.
Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance
between the upper and lower eyelids. The confrontation test measures peripheral vision.
Measuring near vision or the corneal light test does not check for ptosis.
22. When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil
constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to
approximately 7 cm from the nose.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
The nurse is assessing a patients eyes for the accommodation response and would expect to see
which normal finding?
a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes
d. Convergence of the axes of the eyes
Clinical Reasoning Guide: In-Depth Questions,
Answers, and Rationales Covering Visual and
Auditory Systems, Oral and Nasal Health,
Respiratory and Cardiac Function, and Breast
Examination Across the Lifespan Exam
Questions Verified and Provided with A+
Graded Rationales Latest Updated 2026
The nurse is conducting a visual examination. Which of these statements regarding visual
pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance in
the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
b. The image formed on the retina is upside down and reversed from its actual appearance in
the outside world.
The nurse is testing a patients visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
a. Pupillary constriction when looking at a near object
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
d. Constriction of both pupils occurs in response to bright light.
,A mother asks when her newborn infants eyesight will be developed. The nurse should reply:
a. Vision is not totally developed until 2 years of age.
b. Infants develop the ability to focus on an object at approximately 8 months of age.
c. By approximately 3 months of age, infants develop more coordinated eye movements and can
fixate on an object.
d. Most infants have uncoordinated eye movements for the first year of life.
c. By approximately 3 months of age, infants develop more coordinated eye movements and can
fixate on an object.
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
b. Loss of lens elasticity
11. Which of these assessment findings would the nurse expect to see when examining the eyes
of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures
b. Dark retinal background
An ethnically based variability in the color of the iris and in retinal pigmentation exists, with
darker irides having darker retinas behind them.
12. A 52-year-old patient describes the presence of occasional floaters or spots moving in front
of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse
proceed?
,a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.
c. Use the Snellen chart positioned 20 feet away from the patient.
A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets
these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
The top number indicates the distance the person is standing from the chart; the denominator
gives the distance at which a normal eye can see.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take
which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in front of his
or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart
again.
d. Shorten the distance between the patient and the chart until the letters are seen, and record
that distance.
d. Shorten the distance between the patient and the chart until the letters are seen, and record
that distance.
A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that
the patient:
a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
a. Has poor vision.
, The nurse is performing the diagnostic positions test. Normal findings would be which of these
results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
b. Parallel movement of both eyes
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis
of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individuals near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
c. Observe the distance between the palpebral fissures.
Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance
between the upper and lower eyelids. The confrontation test measures peripheral vision.
Measuring near vision or the corneal light test does not check for ptosis.
22. When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil
constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to
approximately 7 cm from the nose.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
The nurse is assessing a patients eyes for the accommodation response and would expect to see
which normal finding?
a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes
d. Convergence of the axes of the eyes
