NURS 502 ADVANCED HEALTH ASSESSMENT EXAM 2024/2025
NURS 502 ADVANCED HEALTH ASSESSMENT EXAM
2024/2025 QUESTIONS AND ANSWERS VERIFIED AND
GRADED A+(SOLVED)
The nurse is performing an eye examination on a 76-yr-old patient. Which finding
indicates that the nurse should refer the patient for a more extensive assessment?
a. The patient's sclerae are light yellow.
b. The patient reports persistent photophobia.
c. The pupil recovers slowly after responding to a bright light.
d. There is a whitish gray ring encircling the periphery of the iris.
B
Photophobia is not a normally occurring change with aging and would require
further assessment. The other assessment data are common gerontologic
differences in assessment and would not be unusual in a 76-yr-old patient.
Which finding by the nurse performing an eye examination indicates that the
patient has normal accommodation?
a. After covering one eye for 1 minute, the pupil constricts as the cover is removed.
b. Shining a light into the patient's eye causes pupil constriction in the opposite
eye.
c. A blink reaction occurs after touching the patient's pupil with a piece of sterile
cotton
,NURS 502 ADVANCED HEALTH ASSESSMENT EXAM 2024/2025
d. The pupils constrict while fixating on an object being moved towards the
patient's eyes
D
Accommodation is defined as the ability of the lens to adjust to various distances.
The pupils constrict while fixating on an object that is being moved from far away
to near the eyes. The other responses may also be elicited as part of the eye
examination, but they do not indicate accommodation.
Which assessment finding alerts the nurse to provide patient teaching about
cataract development?
a. Unequal pupil size
b. Sensitivity to light
c. Loss of peripheral vision
d. History of hyperthyroidism
B
Classic signs of cataracts include blurred vision and light sensitivity. Thyroid
problems are a major cause of exophthalmos. Unequal pupil is not indicative of
cataracts. Loss of peripheral vision is a sign of glaucoma.
A 65-yr-old patient is being evaluated for glaucoma. Which information given by
the patient has implications for the patient's treatment plan?
a. "I take metoprolol (Lopressor) for angina."
,NURS 502 ADVANCED HEALTH ASSESSMENT EXAM 2024/2025
b. "I take aspirin when I have a sinus headache."
c. "I have had frequent episodes of conjunctivitis."
d. "I have not had an eye examination of 10 years"
A
It is important to note whether the patient takes any -adrenergic blockers because
this classification of medications is also used to treat glaucoma, and there may be
an increase in adverse effects. The use of aspirin does not increase intraocular
pressure and is safe for patients with glaucoma. Although older patients should
have yearly eye examinations, treatment will not be affected by the 10-year gap in
eye care. Conjunctivitis does not increase the risk for glaucoma.
A patient who underwent eye surgery must wear an eye patch until the scheduled
postoperative clinic visit. Which patient problem will the nurse address in the plan
of care?
a. Risk for falls
b. Difficulty coping
c. Disturbed body image
d. Inability to care for home
A
The loss of stereoscopic vision created by the eye patch impairs the patient's ability
to see in three dimensions and to judge distances. This increases the risk for falls.
There is no evidence in the assessment data for inability to care for home,
disturbed body image, or difficulty coping.
, NURS 502 ADVANCED HEALTH ASSESSMENT EXAM 2024/2025
The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will
the nurse give the patient before the test?
a. "Hold this card and read the print out loud."
b. "Cover one eye while reading the wall chart."
c. "You'll feel a short burst of air directed at your eyeball."
d. "A light will be used to look for a change in your pupils."
A
The Jaeger card is used to assess near vision problems and presbyopia in persons
older than 40 years of age. The card should be held 14 inches away from eyes
while the patient reads words in various print sizes. Using a penlight to determine
pupil change is testing pupil response. A short burst of air may be used to test
intraocular pressure but is not used for testing presbyopia. Covering one eye at a
time while reading a wall chart at 20 feet describes the Snellen test.
Which action can the nurse working in the emergency department delegate to an
experienced unlicensed assistive personnel (UAP)?
a. Ask a patient with decreased visual acuity about medications taken at home.
b. Perform Snellen testing of visual acuity for a patient with a history of cataracts.
c. Obtain information from a patient about any history of childhood ear infections.
d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.
B
The Snellen test does not require nursing judgment and is appropriate to delegate
to UAP who have been trained to perform it. History taking about infection or
medications and assessment are actions that require critical thinking and should be
done by the RN.
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