What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?
Peripheral vision.
External eye structures.
Distant vision.
Near vision.
The Correct Answer is C
Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.
Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The Review of Systems (ROS) is a systematic approach for collecting the patient's self-reported data on all body systems. It is not typically where the narrative of symptoms is documented. Instead, the ROS is used to uncover symptoms the patient may not have mentioned during the initial recounting of their history.
Choice B Reason:
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient's words¹. While it does include the symptom prompting the visit, it is not the section where a detailed narrative or description of symptoms is provided.
Choice C Reason:
The History of Present Illness (HPI) is indeed where the detailed narrative of the patient's symptoms is documented. It includes the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI tells the story of the patient's chief complaint and provides context for the clinical reasoning process.
Choice D Reason:
The Past Medical History (PMH) includes information about the patient's past experiences with illnesses, operations, injuries, and treatments. It does not contain the current symptoms' narrative but rather the patient's health status before the present illness or concern.
Correct Answer is B
Explanation
Choice A reason:
Palpating in front of the ear would assess the preauricular lymph nodes, not the submental lymph nodes. The preauricular nodes are located just in front of the ears and are typically examined when there is an infection or inflammation in the eyes, ears, or scalp.
Choice B reason:
The submental lymph nodes are located in the midline, just under the chin, behind the bony prominence of the mandible. This is the correct area for palpation when assessing the submental lymph nodes. These nodes drain the lower lip, the floor of the mouth, the tip of the tongue, and the incisors, and they can become enlarged due to infections or malignancies in these areas.
Choice C reason:
Palpating superficial to the sternomastoid would assess the cervical lymph nodes, specifically the anterior cervical nodes, which are not the submental lymph nodes. The sternomastoid muscle is a landmark for several lymph node groups in the neck, but not for the submental group.
Choice D reason:
Palpating at the angle of the mandible would assess the submandibular lymph nodes, not the submental lymph nodes. The submandibular nodes are located beneath the jawline and can become enlarged due to infections or malignancies in the mouth, throat, and salivary glands.
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