3305 Client Assessment Lecture PrepU Mastery Level Questions Chapters 11, 16

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? a. Diabetes b. Retinal detachment c. Renal insufficiency d. Anemia

a. Diabetes

A nursing instructor is teaching students about communication in different cultures. When discussing the meaning of hand gestures and body language in different cultures, the nurse realizes that further instruction is necessary when a student makes which statement? a. "I can make a circle with my thumb and forefinger and people of all cultures know it means OK." b. "A major hand gesture is one for indicating height." c. "If any hand gesture is used, always clarify if there seems to be a strange reaction on the other's part." d. "There are many different elements of body language and hand gestures."

a. "I can make a circle with my thumb and forefinger and people of all cultures know it means OK."

Which vision acuity reading indicates blindness? a. 20/200 b. 20/40 c. 20/20 d. 20/100

a. 20/200

Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client's extraocular movements are asymmetrical and she complains of diplopia. b. Fundoscopic examination reveals intraocular bleeding. c. A client's lens appears cloudy and she claims that her visual acuity has recently declined. d. A client states that he has recently begun seeing lights flashing in his field of vision.

a. A client's extraocular movements are asymmetrical and she complains of diplopia.

In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers? a. Body language b. Pregnancy and childbearing c. Pain d. Death rituals

a. Body language

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response? a. Deep-water fish b. Low-fat meat c. Multigrain foods d. Foods that contain lots of water

a. Deep-water fish

A new graduate nurse, attending a hospital orientation, is asked to explain the goals of a cultural assessment. What would be the graduate nurse's best answer? a. Developing and implementing a culturally congruent plan of care b. Acquiring knowledge about the community's cultural beliefs and practices c. Comparing social and health beliefs of public health agencies d. Comparing social care needs of the specific person

a. Developing and implementing a culturally congruent plan of care

A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what? a. Ethnocentrism b. Ethnicity c. Egocentrism d. Stereotyping

a. Ethnocentrism

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? a. Exotropia b. Presbyopia c. Strabismus d. Esotropia

a. Exotropia

During a client interview, the nurse is focusing on cultural influences particularly when assessing which of the following? Select all that apply. a. High-risk behaviors b. Nutrition c. Health care beliefs and practices d. Employment history e. Cardiovascular status

a. High-risk behaviors b. Nutrition c. Health care beliefs and practices

When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care? a. Improvement of the client's health outcomes b. Improvement of communication with the client and family c. To enhance cultural connectedness d. To enhance the client's social system

a. Improvement of the client's health outcomes

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? a. Lacrimal apparatus b. Vitreous chamber c. Sinus d. Aqueous chamber

a. Lacrimal apparatus

A nurse is performing a focused assessment on a newly admitted client. The client recently emigrated from Central America. The client is talking about the evil eye in a partial use of the dominant language. What is the best response of the nurse? a. Obtain a translator. b. Ask the family, "How long has this been going on?" c. Document abnormal findings for culture. d. Request a Catholic priest.

a. Obtain a translator.

When the nurse asks a client of African origin for the reason for coming to the health clinic, the client responds by saying, "Bad blood." The nurse recognizes that the client is most likely referring to which of the following? a. Sexually transmitted infection b. Low blood volume due to diet c. Sudden collapse preceded by dizziness d. High blood pressure

a. Sexually transmitted infection

What is a characteristic symptom of Graves hyperthyroidism? a. Pinguecula b. Exophthalmos c. Episcleritis d. Pterygium

b. Exophthalmos

What must occur before a client will be willing to teach the nurse about her culture? a. The nurse needs to establish rapport and trust b. The client's family must allow it c. The nurse needs to hide her biases d. The nurse needs to establish a value-based partnership

a. The nurse needs to establish rapport and trust

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client? a. Use of safety equipment b. Prevention of knee injuries c. Prevention of head injuries d. Use of correct foot gear

a. Use of safety equipment

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc? a. White-colored b. Orange-colored c. Oval-shaped d. Blurred margins

a. White-colored

A nurse is conducting a cultural assessment. Which of the following should the nurse include in the assessment? Select all that apply. a. affiliations b. history of mental illness c. values d. physical health e. communication

a. affiliations c. values e. communication

A nurse is assessing a client admitted with anorexia nervosa. The nurse expects which of the following signs and symptoms? a. fear of obesity, restricted food intake b. fear of excessive weight loss, restricted exercise c. weight loss with self-induced vomiting d. fear of weight gain, binge eating

a. fear of obesity, restricted food intake

A client of Native American/First Nations (Navajo) heritage is admitted to the hospital with dizziness, hallucinations, and loss of consciousness. The client is now awake, alert, and oriented. The nurse interviews the client and the client states he has been preoccupied with the death of someone close to him. The client's father states this reaction is common in his culture. Which of the following culture-bound syndromes is this client experiencing? a. ghost sickness b. empacho c. bulimia d. bad blood

a. ghost sickness

A nurse is working in an inner-city clinic with a culturally diverse population. The nurse is orienting a new nurse. Cultural competency is determined when the new nurse states that culture directly affects which of the following? Select all that apply. a. perceptions of health and illness b. intelligence c. biological variation d. health practices e. health outcomes

a. perceptions of health and illness c. biological variation d. health practices e. health outcomes

Which statement by the nurse demonstrates a cultural bias? a. "The client is Muslim, so I'll need to arrange care around his need to pray five times a day." b. "American healthcare is really so much better than that provided by any other country." c. "The client is old and wouldn't be able to understand the discharge instructions." d. "I don't understand how a woman would be sexually interested in another woman."

b. "American healthcare is really so much better than that provided by any other country."

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? a. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" b. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." c. "Please come into the clinic right away so we can see what is wrong." d. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious."

b. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? a. "In children, this problem is usually caused by an increase in pressure within the eye." b. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." c. "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." d. "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals."

b. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

A nurse reviews a client's chart. The nurse learns that the client has been eating only 25% of their meals and has lost 2 lb. (.9 kg.) since admission. The client practices Orthodox Judaism. What action(s) would a culturally competent nurse take? Select all that apply. a. Tell the client, "You need to eat in order to get better." b. Allow the client to arrange times they would like to eat their meals. c. Ask the kitchen to bring the client more of the same food they have been receiving. d. Allow family members to bring food to the client. e. Ask the client about food preferences.

b. Allow the client to arrange times they would like to eat their meals. c. Ask the kitchen to bring the client more of the same food they have been receiving. d. Allow family members to bring food to the client.

A family member of a dying client asks the nurse if they may perform certain rituals, such as praying and reading verses in the private hospital room. How should the nurse respond? a. Inform the family it would be too disruptive. b. Allow the request. c. Deny the request. d. Notify the nursing supervisor.

b. Allow the request.

A younger female nurse is assigned to an older Arab American client. The client tells the nurse that he is uncomfortable having her as his nurse. The client states that he is accustomed to same-gender nurses caring for him. How should the nurse respond? a. Provide the best care despite the client's comment. b. Ask the charge nurse to assign the client to a male nurse. c. Ask the client why he feels that way. d. Reassure the client that he will receive excellent care.

b. Ask the charge nurse to assign the client to a male nurse.

A nurse is conducting a routine cultural assessment on a client of Asian descent for whom the dominant language is a second language. The client's spouse is of African descent. How should the nurse assess the client's cultural identity? a. A cultural assessment is not needed because the client speaks the dominant language. b. Ask the client what culture they identify with. c. Ask the spouse what traditional practices the client participates in. d. Document that the client participates in Asian healing practices.

b. Ask the client what culture they identify with.

A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client? a. Realizing that some women are not allowed an education in their home country b. Assessing if the client speaks and understands English c. Directing assessment questions only to the client's partner or family members d. Requesting a professional translator fluent in the woman's language

b. Assessing if the client speaks and understands English

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment? a. High-velocity injuries are typically non-penetrating b. Blunt-force trauma often results in fracture of the orbit c. This could be a sign of strabismus d. The client could have optic atrophy

b. Blunt-force trauma often results in fracture of the orbit

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? a. Allergies b. Brain tumor c. Viral infection d. Vitamin A deficiency

b. Brain tumor

A nurse is assessing a client from India who complains of panic, sexual dysfunction, fatigue, weakness, and loss of appetite. Which culture-bound syndrome should the nurse suspect in this client? a. Wind illness b. Dhat c. Latah d. Koro

b. Dhat

A client of African descent tells the nurse they communicate with the dead. How should the nurse respond? a. Perform a comprehensive neurological exam. b. Document the client's statement. c. Request a psychiatric consultation. d. Document that the client is hearing voices.

b. Document the client's statement.

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action? a. Have the client state when they see the nurse's finger enter their peripheral vision field. b. Observing the eye's reaction when a light is shone into the opposite eye c. Comparing the difference between the client's dilated pupil and a constricted pupil d. Shining a light into one eye while covering the other eye with an opaque card

b. Observing the eye's reaction when a light is shone into the opposite eye

The nurse reviews the nursing notes (above) as well as the cultural assessment notes which indicate that the parents value high weights in infants. The nurse should do which of the following? a. Demonstrate for the parents how to weigh diapers. b. Provide education related to infant formula consumption and overfeeding. c. Demonstrate for the parents how to burp the infant to reduce vomiting. d. Provide education related to preventing constipation in infants.

b. Provide education related to infant formula consumption and overfeeding.

When testing the near reaction, an expected finding includes which of the following? a. Pupillary dilation on near gaze; dilation on distant gaze b. Pupillary constriction on near gaze; dilation on distant gaze c. Pupillary constriction on near gaze; constriction on distant gaze d. Pupillary dilation on near gaze; constriction on distant gaze

b. Pupillary constriction on near gaze; dilation on distant gaze

The nurse is conducting a health history of the client who presents to the urgent care with complaints of shortness of breath. The nurse asks, "Who lives with you?" Which type of assessment is the nurse conducting? a. Biological assessment b. Social assessment c. Spiritual assessment d. Psychological assessment

b. Social assessment

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? a. Have the client read from a Jaeger reading card b. Use a Snellen E chart to perform the examination c. Perform the confrontation test d. Move an object through the six cardinal positions of gaze

b. Use a Snellen E chart to perform the examination

The nurse should make it a priority to assess which client for papilledema? a. a 56-year-old reporting double vision b. a 45-year-old suspected of experiencing a subarachnoid hemorrhage c. a 12-year-old demonstrating a deviated left eye d. an 80-year-old diagnosed with chronic open-angle glaucoma

b. a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The conjunctiva of the eye is divided into the palpebral portion and the a. intraocular portion. b. bulbar portion. c. canthus portion. d. nasolacrimal portion.

b. bulbar portion.

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's a. phoria. b. esotropia. c. exotropia. d. strabismus.

b. esotropia.

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for a. double vision. b. lacrimal obstruction. c. viral infection. d. allergic reactions.

b. lacrimal obstruction.

A nursing student realizes that which of the following is an important variation of communication? a. spirituality b. silence c. death rituals d. beliefs

b. silence

What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply. a. reasons for immigrating to the United States b. whether there are any existing language barriers c. nutritional or dietary considerations d. age when immigration to the United States occurred e. alternative medicine practices

b. whether there are any existing language barriers c. nutritional or dietary considerations e. alternative medicine practices

The nurse is assessing a client in the emergency department who appears to be confused and unable to follow commands. When obtaining the client's social history, which of the following questions should the nurse ask first? a. "Are you married?" b. "Are you able to afford your medications?" c. "Have you consumed any alcohol today?" d. "Do you live in low-income housing?"

c. "Have you consumed any alcohol today?"

Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness? a. "I understand a client's culture if I am familiar with the client's ethnic values." b. "A person's race is an effective characteristic of his or her cultural background." c. "I need to understand the client's cultural background to best interpret the client's needs." d. "A disability is not a factor in determining a client's cultural needs."

c. "I need to understand the client's cultural background to best interpret the client's needs."

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? a. Eyelid b. Limbus c. Conjunctiva d. Lacrimal apparatus

c. Conjunctiva

A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting? a. Cultural skill b. Conscious incompetence c. Cultural desire d. Cultural knowledge

c. Cultural desire

A nurse is performing an admission assessment of a client of Asian descent who participates in traditional cultural practices. During the assessment the nurse observes large, round, red marks on the client's back. What action should the nurse take? a. Ask the client's spouse to leave the room. b. Report findings of abuse to the nursing supervisor. c. Document findings. d. Notify the health care provider of abnormal findings.

c. Document findings.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? a. Epicanthus b. Ptosis c. Exophthalmos d. Ectropion

c. Exophthalmos

What is a characteristic symptom of Graves hyperthyroidism? a. Pinguecula b. Episcleritis c. Exophthalmos d. Pterygium

c. Exophthalmos

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis? a. Sluggish pupillary reaction b. Displaced optic nerve c. Increased intraocular pressure d. Opaque lens

c. Increased intraocular pressure

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions? a. Australia and New Zealand. b. Central and South America. c. Mediterranean and Africa. d. Northern and Central Europe.

c. Mediterranean and Africa.

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? a. Test the pupils for direct and consensual reaction to light b. Obtain a referral to the ophthalmologist for a complete eye exam c. Perform both the distant and near visual acuity tests d. Document the findings in the client's record

c. Perform both the distant and near visual acuity tests

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? a. Loss of convergence b. Cataract formation c. Presbyopia d. Macular degeneration

c. Presbyopia

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data? a. Ineffective Individual Coping b. Disturbed Self Concept c. Risk for Injury d. Self-Care Deficit

c. Risk for Injury

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? a. Client's consensual pupil constricts in response to indirect light. b. Direct light shown into the client's pupils results in constriction. c. The client and the examiner see the examiner's finger at the same time. d. Eyes converge on an object as it is moved towards the nose.

c. The client and the examiner see the examiner's finger at the same time.

The functional reflex that allows the eyes to focus on near objects is termed a. refraction. b. pupillary reflex. c. accommodation. d. indirect reflex.

c. accommodation.

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's a. eyelid reflexes. b. lacrimal reflexes. c. corneal reflexes. d. refractory mechanism.

c. corneal reflexes.

A male nurse is caring for an elderly woman who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the client, she refuses to allow it. The best explanation for her actions would be which of the following? a. depression b. confusion c. cultural differences d. fear in strange surroundings

c. cultural differences

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope a. in the right hand for both eyes b. in the left hand for both eyes c. in the right hand for the right eye and in the left hand for the left eye d. in the left hand for the right eye and in the right hand for the left eye

c. in the right hand for the right eye and in the left hand for the left eye

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent a. hemianopsia b. retinal detachment c. macular degeneration d. open-angle glaucoma

c. macular degeneration

The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan a. contact number for the cardiac rehabilitation program at the medical center. b. referral to a cardiac specialist. c. nutritional information specifically for the client's culture. d. educational materials given to all clients with hypertension.

c. nutritional information specifically for the client's culture.

A new nurse is caring for a group of clients. A charge nurse intervenes when observing which of the following actions by the new nurse? a. allowing a Jehovah's Witness client with severe anemia to refuse blood products b. barely making eye contact while speaking to a client of Native American/First Nations heritage c. performing an admission assessment using the client's son as an interpreter d. addressing the husband of a client whose family structure is paternalistic

c. performing an admission assessment using the client's son as an interpreter

When performing a cultural assessment, an important point to remember would be a. to use first names of those you are speaking to b. that the cultural/ethnic background is evident in the client's appearance c. that definitions of family differ d. that alternative therapies are reasons for seeking care

c. that definitions of family differ

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? a. "How often do you have redness or tearing?" b. "Do you see floaters in front of your eyes?" c. "Is night blindness a problem for you?" d. "Are the blind spots constant or intermittent?"

d. "Are the blind spots constant or intermittent?"

Which statement by the nurse indicates the best understanding of the purpose of an eye-related health history? a. "The history encourages the client to reflect upon the state of client's eyes and vision." b. "The history allows the client to discuss their vision-related problems." c. "The nurse is able to visualize the client's eye with the benefit of an ophthalmoscope." d. "Broad, open-ended questions provide an opportunity to identify changes in the client's eyes."

d. "Broad, open-ended questions provide an opportunity to identify changes in the client's eyes."

A client is scheduled for surgery. The client asks the nurse if they could speak to a priest before surgery. What is the best response of the culturally competent nurse? a. "Are you feeling okay? Do you want me to call your family?" b. "That is an unusual request to make before surgery." c. "I will check with my supervisor." d. "I will see if I can get a priest to visit you before surgery."

d. "I will see if I can get a priest to visit you before surgery."

A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover? a. Prayers to God and saints for spiritual reparations for sins b. Respect for nature and use of masks and sand paintings c. Use of herbs, roots, talismans, and amulets d. A focus on maintaining balance between yin and yang

d. A focus on maintaining balance between yin and yang

A nurse wants to determine their own tendencies to stereotype. Which of the following mnemonics should the nurse use to assess their cultural competence and biases? a. BIAS b. RACE c. QUESTION d. ASKED

d. ASKED

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? a. When 50 feet from the chart, the client can see better than a person standing at 20 feet. b. Client can read the 20/50 line correctly and two other letters on the line above. c. Client did not wear his glasses for this test and therefore it is not accurate. d. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

d. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

The nurse knows that she will be caring for a client from Southern Korea who has been visiting with a family member. The nurse obtains some information about the Korean culture so that she will be able to meet the clients needs. What is the nurse demonstrating? a. Unconscious incompetence b. Cultural assessment c. Unconscious competence d. Cultural knowledge

d. Cultural knowledge

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? a. Place the client 20 feet from the Snellen chart and record the smallest line the client can read b. Sit the client in front of the examiner, extend one arm, and slowly move one finger upward c. Tell the client to remove glasses, if present, and read the Snellen card using both eyes d. Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

d. Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? a. Upward toward the forehead b. Downward toward the chin c. Laterally toward the ear d. Medially toward the nose

d. Medially toward the nose

the nurse asks the client to perform the action pictured. What is the nurse assessing? a. Distance vision b. Color discrimination c. Intraocular pressure d. Near vision

d. Near vision

Which of the following statements is true of cultural groups and magico-religious beliefs in their health belief systems? a. Hispanic culture has religious beliefs but not magico-religious beliefs. b. Western majority culture does not have magico-religious beliefs. c. Afro American culture has magic beliefs but not religious beliefs. d. No culture is without an element of magico-religious beliefs.

d. No culture is without an element of magico-religious beliefs.

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? a. Obtain a referral to the ophthalmologist for a complete eye exam b. Test the pupils for direct and consensual reaction to light c. Document the findings in the client's record d. Perform both the distant and near visual acuity tests

d. Perform both the distant and near visual acuity tests

In order to effectively examine a client's eyes with an ophthalmoscope, the nurse should follow which procedure related to this piece of equipment? a. Place the ophthalmoscope in the left hand and look through the right eye. b. Remove eyeglasses before looking into the ophthalmoscope. c. Close the eye that is not looking through the ophthalmoscope during the examination. d. Place the ophthalmoscope in the right hand and look through the right eye.

d. Place the ophthalmoscope in the right hand and look through the right eye.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? a. She can accurately name 20% of the letters at 20 feet. b. She obtains a 20% correct score at 100 feet. c. She can see at 100 feet what a normal person could see at 20 feet. d. She can see at 20 feet what a normal person could see at 100 feet.

d. She can see at 20 feet what a normal person could see at 100 feet.

When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care? a. Develop a plan of care based on the nurse's own knowledge of a client's culture. b. Develop a plan of care after talking to the client's family. c. After the focused assessment, decide if a cultural assessment is necessary. d. Show genuine interest in the client's culture and personal life experiences.

d. Show genuine interest in the client's culture and personal life experiences.

The nurse is educating a client from another country about the medications they will be taking. The client continually interrupts the nurse during the conversation. When the nurse considers the many ways cultural differences can affect communication, how should the nurse interpret the client's interruptions? a. The client believes that they know more about the medications than the nurse does. b. This client is impolite and does not know good manners. c. The client believes that what they have to say is more important than what the nurse is saying. d. The client is deeply engaged in the conversation.

d. The client is deeply engaged in the conversation.

The meibomian glands secrete a. clear liquid tears. b. sweat. c. hormones. d. an oily substance to lubricate the eyes.

d. an oily substance to lubricate the eyes.

A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding? a. positive corneal reflex b. negative for nystagmus c. equal accommodation d. consensual reflexes observed

d. consensual reflexes observed

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents a. ptosis b. exophthalmos c. ectropion d. entropion

d. entropion

Stereotyping is defined as a. the belief that one's cultural values are superior to all others. b. a culture-bound syndrome found in many cultural groups. c. a worldview that each of us forms values and beliefs based on our own culture. d. expecting all members of a cultural group to hold the same beliefs and behave in the same way.

d. expecting all members of a cultural group to hold the same beliefs and behave in the same way.

The optic nerves from each eyeball cross at the a. visual cortex. b. vitreous humor. c. optic disc. d. optic chiasma.

d. optic chiasma.

Photoreceptors of the eye are located in the eye's a. pupil. b. lens. c. ciliary body. d. retina.

d. retina.

The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is a. study transcultural nursing texts and articles about the group. b. do a community survey of the areas where the ethnic group lives. c. interview the traditional healers within the group. d. spend time with a variety of individuals of that ethnic group.

d. spend time with a variety of individuals of that ethnic group.