HA 2 exam eye tests
Confrontation test
-Confront the peripheral , Testing peripheral vision - The Tester Covers the same eye for tester and testee. The tester moves their hand around in the peripheral. If tester sees it, then the testee should see it too. -Tester must have good vision to do this test to testee.
a Person with which type of eye disease will have a hard time with a Confrontation test?
-Glaucoma sufferers will most likely fail this test because they have a hard time with peripheral vision.
Pupillary Light Reflex
-Hand at nose to separate viewing area for vision. -Tester makes Light comes in from the side The DIRECT RESPONSE is the eye constricting to that light. THE CONSENSUAL RESPONSE is the other eye (who did not see the light) restricting as well.
Diagnostic Positions Test (Cardinal Fields of Gaze)
-Lead the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement. -Ask person to hold head steady and follow finger. -Progress clockwise in each direction. -A normal response is parallel tracking of the object with both eyes -Tests Cranial nerves III (Occulomotoer), IV (Trochlear), and VI (Abducens)
To test for Perrla, which 2 tests do we need?
-Pupillary light reflex & -Accommodation Test
snellen eye chart
20/20 numerator is distance at which you are standing denominator is the distance someone else with 20/20 vision stands to read the same thing you were able to read. The larger the denominator, the poorer the vision
Extraocular eye muscle function which cranial nerves are used?
3,4,6
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact
A
A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? a. Clear b. Malodorous c. Yellow d. Green P. 145
A
An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patient's auditory canal? a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal. b. Remove cerumen from each canal before inserting otoscope. c. Choose the smallest otoscope speculum that will fit the patient's ear comfortably. d. Pull the pinna slightly downward and backward before inserting the otoscope speculum.
A
What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland? a. "Swallow for me one time." b. "Flex your head down and to the left." c. "Rotate your head to the right for me." d. "Hold your breath for a few seconds."
A
When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve? a. Pupillary constriction to light b. Visual acuity c. Peripheral vision d. Presence of the red reflex
A
When inspecting a patient's nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate
A
When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins? a. The arteries are narrower than veins. b. The arteries are a darker red than veins. c. The arteries have no light reflex and the veins have a narrow band of light in the center. d. The arteries have prominent pulsations and veins have no pulsations.
A
Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)
A
Which finding indicates that this patient has a sensorineural hearing loss? a. The patient hears sound by air conduction longer than by bone conduction. b. The patient hears sound from a vibrating tuning fork in the affected ear only. c. The patient hears normal conversation at 40 dB and a whisper at 20 dB. d. The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.
A
A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing? a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC). b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC). c. Sound lateralizes to the affected ear on the Weber test. d. Sound lateralizes to both ears equally on the Weber test.
B
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.
B
A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage P. 145
B
A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located? a. In front of the ear b. Under the mandible c. At the base of the skull d. Along the angle of the jaw
B
After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the nurse locate the optic disc? a. By rotating the diopter to the block (positive) numbers until the optic disc comes into focus b. By following the retinal vessels inward toward the nose until optic disc is seen c. By using the green beam light while looking outward toward the ear until the disc is seen d. By locating the macula and then looking temporally (toward the ear) until the disc is seen
B
During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia
B
During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse? a. Repeat the test again using a 2000 Hz tuning fork. b. Tell the patient that this represents an expected finding. c. Refer the patient for additional testing to detect hearing abnormality. d. Perform a Weber test to confirm the findings of the Rinne test.
B
During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes? a. Anterior chamber depth is shallow. b. Red reflex is absent. c. Extraocular muscle movement is asymmetric. d. Retinal arteries are wider than retinal veins.
B
How does the nurse perform a Weber test to assess hearing function? a. Whispers three to four words into the patient's ear and asks him to repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound
B
How does the nurse test the function of the patient's spinal accessory nerve (CN XI)? a. Ask the patient to stick out the tongue and move it side to side. b. Ask the patient to shrug the shoulders against the resistance of the nurse's hands. c. Ask the patient to open the mouth and observe the uvula rise when he says "ah." d. Ask the patient to move the chin to the chest and then up toward the ceiling.
B
The nurse palpates the patient's jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw? a. Clinch the jaws together as tightly as possible. b. Move the lower jaw from side to side. c. Open the mouth as wide as possible, like a yawn. d. Move the lower jaw forward and backward several times. P. 149
B
To assess jaw movement of an adult patient, the nurse uses which technique? a. Asking the patient to open the mouth and then passively moving the patient's open jaw from side to side b. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth c. Asking the patient to open the mouth and to resist the nurse's attempt to close the mouth d. Using the pads of all fingers to feel along the mandible for tenderness and nodules p. 149 FIG 10-15
B
Which finding on assessment of a patient's eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally
B
During an examination of the head and neck of a healthy adult, the nurse expects which findings? Select all that apply. a. Small red lesions with white flakes scattered on the scalp b. The head and facial bones are proportional for the size of the body c. Depressions palpated on the right and left sides over the parietal bones d. Head held flexed 15 degrees to the left e. Face and jaw are symmetric and proportional f. Temporomandibular joint moves smoothly
B, E, F
A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patient's corneal light reflex.
C
A nurse uses which technique to assess a patient's peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.
C
During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test? a. Air conduction will be twice as long as bone conduction (2:1 ratio). b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio). c. Bone conduction will be longer than air conduction. d. Bone conduction will be equal to air conduction.
C
During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered eye
C
How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test
C
What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. "Remove your eyeglasses before attempting to read the lowest line." b. "Stand 10 feet from the chart and read the first line aloud." c. "Hold a white card over one eye and read the smallest possible line." d. "Squint if necessary to improve the ability to read the largest letters." P. 149
C
While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient? a. The patient's eyes move to the left, right, up, down, and obliquely during conversation. b. The patient moistens the lips with the tongue. c. The sides of the mouth are symmetric when the patient smiles. d. The patient's eyelids blink periodically. P. 137
C (Since the facial cranial nerves control symmetry)
Two things should happen when you change your eyes from looking at a far away object to a near object
Convergence and Constriction constrict to accommodate and converge to accomodate
A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal? a. Clear fluid lining the auditory canal b. A firm tympanic membrane without fluctuation with puffs of air c. A small hole within the cone of light d. A shiny, translucent tympanic membrane
D
A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection? a. The soft palate illuminates brightly when the light source is placed against the lateral nose. b. No illumination is noted when the light source is placed firmly against the lateral nose. c. A bright glow illuminates the hard palate when the light source is placed against each temporal bone. d. A reddish light is noted above the eyebrows when the light is placed against each supraorbital rim.
D
How does a nurse recognize normal accommodation? a. The patient has peripheral vision of 90 degrees left and right. b. The patient's eyes move up and down, side to side, and obliquely. c. The right pupil constricts when a light is shown in the left pupil. d. The patient's pupils dilate when looking toward a distant object.
D
How does the nurse perform a Rinne test of hearing function? a. Whispers several words to the patient and requests that the patient repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it
D
On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation
D
Which finding warrants a referral for additional evaluation? a. Earlobes hanging freely from the base of the pinna b. Ears having painless nodules less than 1 cm in diameter at the helix c. Ears measuring 8 cm in length d. Pinna is 20 degrees lower than the outer canthus of the eye
D
Which tests do we use to test Extraocular eye muscle function?
First do the Corneal Light Reflex if test is abnormal, go to next test which is Cover test. Diagnostic Positions Test (Cardinal Fields of Gaze)
Cover test
Have patient cover one eye. make sure that uncovered eye doesn't bounce around. Then check covered eye to see if it jumps around as well. The eye muscle should not jump on either eye.
Perrla means
Pupils equal, round, reacting to light, and accommodation
Corneal Light reflex
Take a penlight right to the middle of the eyes. You should see a reflection in the same spot on each eye. Record your findings as such. Example: Reflection is noted at the 2 oclock position bilaterally If this test comes up abnormally, then you would proceed to do the cover test.
Accommodation Test
The Testee looks over the Testers shoulder at a far away object (clock) Now the Testee looks at the Testers Nose. Eyes should dilate to look at the far away object (clock) and eyes should constrict when looking at the Testers Nose (near object), Thie eye should accommodate to the near object.
snellen eye chart
Visual acuity test
She said almost every eye test will be on her test while she was lecturing
a little bit later she said she really wants us to know Pupillary Light reflex, Perrla, Diagnostic test, confrontation test, and corneal light reflex. Im just going to study this whole eye quizlet i made.
Convergence
is the ability of the eye to simultaneously demonstrate inward movement of both eyes toward each other. This is helpful in effort to make focus on near objects clearer. This should happen when looking at a far away object and then a near object.
