Health assessment exam 3 Fall 2023
The nurse is preparing to perform a Weber test on a client. The nurse would obtain which item needed to perform this test? 1 A tuning fork 2 A stethoscope 3 A tongue blade 4 A reflex hammer
1 A tuning fork A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client's forehead or above the upper lip over the teeth. Normally the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in the remaining options are not needed to perform the Weber test.
The nurse would ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)? 1 Elevate the shoulders. 2 Swallow a sip of water. 3 Open the mouth and say "aah." 4 Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."
1 Elevate the shoulders. The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, to resist attempts to pull the chin toward midline, and to push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.
The nurse is testing a client for astereognosis. The nurse would ask the client to close the eyes and perform which action? 1 Identify an object placed in the client's hand. 2 Identify three numbers or letters traced in the client's palm. 3 State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place. 4 Identify the smallest distance between two detectable pinpricks, made with two pins held at various distances.
1 Identify an object placed in the client's hand. Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Graphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and two-point stimulation, respectively.
The nurse is preparing to perform an otoscopic examination on an adult client. Which action would the nurse take to perform this examination? 1 Pull the pinna up and back before inserting the speculum. 2 Pull the earlobe down and back before inserting the speculum. 3 Tilt the client's head forward and down before inserting the speculum. 4 Use the smallest speculum available to decrease the discomfort of the exam.
1 Pull the pinna up and back before inserting the speculum. The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.
The nurse is performing a neurological assessment on a client with a head injury. The nurse would use which technique to assess the plantar reflex? 1 Stroking the foot from the heel to the toe 2 Gently inserting a gloved finger in the rectum 3 Directing a flashlight onto the pupils of the eyes 4 Using a tongue depressor and stimulating the back of the throat
1 Stroking the foot from the heel to the toe The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.
The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the five "Ps" to assess the extent of the client's injury. What are some of the five "Ps"? Select all that apply. 1 Pallor 2 Pain and point of tenderness 3 Paralysis distal to the fracture site 4 Pulses proximal to the fracture site 5 Sensation distal to the fracture site
1, 2, 3, 5 If a child sustains a fracture, the extent of the injury is immediately assessed using the five "P's"—pain and point of tenderness, pulses distal (not proximal) to the fracture site, pallor, paresthesia (sensation) distal to the fracture site, and paralysis (movement distal to fracture site).
The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1 Turn the flashlight on directly in front of the eye and watch for a response. 2 Ask the client to follow the flashlight through the six cardinal positions of gaze. 3 Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4 Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.
2 Ask the client to follow the flashlight through the six cardinal positions of gaze. The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.
The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test? 1 Tuning fork and audiometer 2 Cloves, peppermint, and soap 3 Flashlight, pupil size chart, and millimeter ruler 4 Safety pin, hot and cold water in test tubes, and cotton wisp
2 Cloves, peppermint, and soap The sensory function of the olfactory nerve controls the sense of smell. To test this nerve, the nurse would ask the client to close the eyes and occlude 1 nostril and identify a nonirritating and familiar odor such as coffee, tea, cloves, soap, chewing gum, or peppermint. The test is then repeated on the other nostril. The supplies noted in the remaining options are used for testing cranial nerves VIII, II, and V, respectively.
The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse would ask the client to take which action? 1 Focus on a close object. 2 Focus on a distant object. 3 Close 1 eye and read letters on a chart. 4 Raise 1 finger when the sound is heard.
2 Focus on a distant object. The nurse tests for accommodation by initially asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 in (7.5 cm) from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes. INITIALLY is the key word!
The nurse is testing a client for graphesthesia and asks the client to close the eyes. The nurse would next ask the client to take which action? 1 Identify three objects placed in the hand, one at a time. 2 Identify three numbers or letters traced in the client's palm. 3 Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances. 4 State whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.
2 Identify three numbers or letters traced in the client's palm. Graphesthesia is the ability to recognize the form of written symbols. The nurse can assess for this by tracing symbols, such as numbers, in the client's palm. Option 1 tests for stereognosis, which is the ability to identify the form of common objects using the sense of touch. Options 3 and 4 test for extinction phenomenon and two-point stimulation, respectively.
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the motor function of this nerve? 1 Ask the client to puff out the cheeks. 2 Separate the client's jaw by pushing down on the chin. 3 Place a small amount of sugar on the client's tongue and ask them to identify the taste. 4 Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.
2 Separate the client's jaw by pushing down on the chin. The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles would feel equally strong on both sides. The nurse would try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.
The nurse is performing a physical examination on an assigned client. Which item would the nurse select to test the function of cranial nerve II? 1 Flashlight 2 Snellen chart 3 Reflex hammer 4 Ophthalmoscope
2 Snellen chart Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina.
The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? 1 Stand 10 ft (3 meters) from the chart and cover 1 eye. 2 Stand 20 ft (6 meters) from the chart and cover 1 eye. 3 Stand 30 ft (9 meters) from the chart and read the largest line on the chart. 4 Stand 40 ft (12 meters) from the chart and read the largest line on the chart.
2 Stand 20 ft (6 meters) from the chart and cover 1 eye. Visual acuity is assessed in one eye at a time and then in both eyes together, with the client comfortably standing or seated. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 ft (6 meters) from the chart. The right eye is tested first with the left eye covered; then the left eye is tested with the right eye covered; and then both are tested together.
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse would implement which assessment technique to assess for muscle weakness in the eye? 1 Test the corneal reflexes. 2 Test the six cardinal positions of gaze. 3 Test visual acuity, using a Snellen eye chart. 4 Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.
2 Test the six cardinal positions of gaze. Testing the six cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close the eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).
The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what would the nurse test? 1 The corneal reflex 2 The six cardinal fields of gaze 3 The pupillary response to light 4 Pupillary response to light and accommodation
2 The six cardinal fields of gaze Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the six cardinal fields of gaze. This is tested by moving an object in six directions (involving horizontally and diagonally). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response to light and accommodation is the function of cranial nerve III (oculomotor) alone.
The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply. 1 Presence of fasciculations 2 Muscle strength graded 5/5 3 Symmetrical movements bilaterally 4 Increased muscle size on the dominant arm 5 A 1-cm hypertrophy of the right upper arm
2, 3, 4, 5 Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.
A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? 1 "I will tell you when I see the colored dots." 2 "I will tell you when I see the flash of bright light." 3 "I will tell you when the small object is in my visual field." 4"I will tell you when the blocks and shapes are in my visual field."
3 "I will tell you when the small object is in my visual field." The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner approximately 2 ft (60 cm) away. The eyes of the client and the examiner need to be at the same level. Both the examiner and the client cover the eyes directly opposite to one another and stare at each other's uncovered eye. A small object is brought in from the peripheral visual field, and the superior, temporal, inferior, and nasal fields are evaluated. The client states when the object is seen.
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How would the nurse explain these results to the client? 1 "You have normal vision." 2 "You have some degree of blindness." 3 "You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." 4 "You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."
3 "You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." When recording visual acuity as measured by the Snellen chart, the nurse would record the numerical fraction noted at the end of the last line successfully read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/30 means that the client can read at a distance of 20 ft (6 meters) what a client with normal vision can read at 30 ft (9 meters). Normal visual acuity is 20/20. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or less.
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1 A defect in the cochlea 2 A defect in cranial nerve VIII 3 A physical obstruction to the transmission of sound waves 4 A defect in the sensory fibers that lead to the cerebral cortex
3 A physical obstruction to the transmission of sound waves A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear such as a defect in the cochlea, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.
The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 1 Ataxia 2 Nystagmus 3 Pronator drift 4 Hyperreflexia
3 Pronator drift Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.
The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1 An involuntary rhythmic, rapid twitching of the eyeballs 2 A dorsiflexion of the ankle and great toe with fanning of the other toes 3 A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4 A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
3 A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.
The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse would obtain which item to test the sensory function of this nerve? 1 Coffee beans 2 A tuning fork 3 A wisp of cotton 4 An ophthalmoscope
3 A wisp of cotton To assess the sensory function of cranial nerve V (the trigeminal nerve), the nurse would ask the client to close the eyes and then with a wisp of cotton lightly touch the client's forehead, cheeks, and chin, noting whether the touch is felt equally on both sides of the face. Cranial nerve I (the olfactory nerve) is assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell. A tuning fork would be used to assess cranial nerve VIII (the acoustic nerve). An ophthalmoscope would be used to assess the internal structures of the eye.
Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? 1 Ask the client to clench the teeth. 2 Ask the client to read the letters in a line on a Snellen chart. 3 Ask the client to shrug the shoulders against the nurse's resistance. 4 Ask the client to close the eyes, occlude one nostril, and identify a specific odor such as coffee.
3 Ask the client to shrug the shoulders against the nurse's resistance. The spinal accessory nerve, cranial nerve XI, controls strength of the neck and shoulder muscles. One method of testing this nerve is to palpate and inspect the trapezius muscle as the client shrugs the shoulders against the nurse's resistance. Option 1 tests cranial nerve V, the trigeminal nerve. Option 2 tests cranial nerve II, the optic nerve. Option 4 tests cranial nerve I, the olfactory nerve.
The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1 Complaints of ringing in the ear 2 An excessive amount of cerumen in the ear canal 3 Intolerance for sound levels that do not bother other people 4 Complaints of dizziness and sensations of being "off balance"
3 Intolerance for sound levels that do not bother other people Complaints of ringing in the earAn excessive amount of cerumen in the ear canalIntolerance for sound levels that do not bother other peopleComplaints of dizziness and sensations of being "off balance"
A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? 1 A wider-than-normal ear canal 2 A pearly gray tympanic membrane 3 Redness and swelling in the ear canal 4 An excessive amount of cerumen lodged in the ear canal
3 Redness and swelling in the ear canal External otitis is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal and can lead to temporary hearing loss from obstruction. The tympanic membrane is not usually affected in external otitis. Cerumen does not cause external otitis; however, external otitis can result if a person uses a sharp or small object that traumatizes the external ear when trying to remove the cerumen.
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1 The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2 The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3 The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4 The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
3 The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there would be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? 1 "The client's vision is normal, but the client may require reading glasses." 2 "The client is legally blind, and glasses or contact lenses will not be helpful." 3 "The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." 4 "The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."
4 "The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)." Vision that is 20/20 is normal; that is, the client is able to read at 20 ft (6 meters) what a person with normal vision can read at 20 ft (6 meters). A client with a visual acuity of 20/40 can read at a distance of only 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters).
The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and would perform which action? 1 Ask a second nurse to be present during the interview. 2 Defer both the health history and the neurological examination. 3 Defer the health history and proceed with the neurological examination. 4 Ask the client to give permission for a family member to stay during the interview.
4 Ask the client to give permission for a family member to stay during the interview. The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse would ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.
The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? 1 Tapping the Achilles tendon using the reflex hammer 2 Gently pricking the client's skin on the dorsum of the foot in two places 3 Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4 Holding the sides of the client's great toe and, while moving it, asking what position it is in
4 Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in two different places describes two-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.
The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? 1 Whisper a statement while the client blocks both ears. 2 Quietly whisper a statement and test both ears at the same time. 3 Whisper a statement with the examiner's back to the client. 4 Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block one external ear canal.
4 Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block one external ear canal. To perform a voice test, the examiner stands 1 to 2 ft (30 to 60 cm) away from the client and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner would face the client during the test.
A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? 1 The client is asked to discriminate numbers from a chart composed of colored dots. 2 The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. 3 The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. 4 The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.
4 The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field. The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner, approximately 2 ft (60 cm) away. The eyes of the client and the examiner need to be at the same level. Both the examiner and the client cover the eyes directly opposite each other and stare at each other's uncovered eye. A small object is brought from the peripheral visual field and tests the superior, temporal, inferior, and nasal field. The client states when they see the object.
A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange the actions in the order that they would be performed. All options must be used. 1 Asks the client to cover one eye 2 Examiner covers eye opposite to the eye covered by the client 3 Asks the client to report when object is first noted 4 Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5 The examiner brings in an object gradually from periphery
4, 1, 2, 5, 3 The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client needs to be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face the client; client covers one eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.
