Physical Examination & Health Assessment

1. When examining the eye, the nurse notices that the patient’s eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure. ANS: A The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 281 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 2. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI. ANS: Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 283 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 3. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye. ANS: The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 283 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 4. When examining a patient’s eyes, the nurse recalls that stim...

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