Review Practice Exercise 2

Health and Physical Assessment of the Adult Client > Fundamentals

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Practice Exercise 2

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Total Questions : 4

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Question 1:

When assessing a patient’s eyes, which instrument would the nurse use to visualize the retina?

A. Otoscope B. Ophthalmoscope C. Stethoscope D. Tuning fork

Answer and Explanation

Choice A:

toscope: This instrument is used to inspect the ear canal and tympanic membrane (eardrum). It has a light and magnifying lens, but it is not designed to examine the eye.

Choice B:

Ophthalmoscope: The ophthalmoscope is a handheld instrument used to examine the interior of the eye, particularly the retina, optic disc, blood vessels, and macula.

Choice C:

tethoscope: A stethoscope is used to auscultate sounds in the body, such as heart, lung, and bowel sounds. It plays no role in eye assessment.

Choice D:

uning fork: A tuning fork is typically used for hearing and vibration tests, such as the Rinne or Weber test, or to assess peripheral neuropathy. It has no function in examining the eye.

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Question 2:

Which technique would a nurse use to assess skin turgor?

A. Indent area with fingertips B. Use a special type of lighting C. 3. Touch the area to detect moisture D. Lightly pinch a fold of skin

Answer and Explanation

Choice A:

ndent area with fingertips: This technique is used to assess for pitting edema, not skin turgor. The nurse presses the skin (often over the shin or ankle) to observe if an indentation remains.

Choice B:

Use a special type of lighting: Special lighting, like tangential or oblique lighting, may help visualize skin lesions, rashes, or color changes, but it does not assess elasticity or turgor.

Choice C:

Touch the area to detect moisture: Touching the skin helps assess temperature or moisture (e.g., dry, clammy, diaphoretic skin) but not elasticity.

Choice D:

Lightly pinch a fold of skin: To assess skin turgor, the nurse gently pinches a fold of skin, usually on the forearm, sternum, or abdomen, and then releases it. If the skin quickly returns to its normal position, turgor is normal.

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Question 3:

A patient’s visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as which of the following?

A. The patient can see twice as well as normal B. The patient has double vision C. The patient has less than normal vision D. The patient has normal vision

Answer and Explanation

Choice A:

The patient can see twice as well as normal: This is the opposite of what 20/40 means. The patient sees less clearly, not better.

Choice B:

The patient has double vision: Double vision is known as diplopia, which refers to seeing two images of one object. It is a separate issue and not measured by the Snellen chart.

Choice C:

The patient has less than normal vision: A 20/40 Snellen result means the patient can see at 20 feet what a person with normal vision can see at 40 feet. This indicates reduced visual acuity, or less than normal vision. It may warrant further evaluation or correction (e.g., glasses).

Choice D:

The patient has normal vision: Normal visual acuity is defined as 20/20. A 20/40 result is below normal and may affect tasks like reading small print or driving.

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Question 4:

When using an otoscope to assess the tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction?

A. Up and back B. Down and forward C. Away from the examiner D. In any direction

Answer and Explanation

Choice A:

Up and back: In adults, the ear canal curves upward and backward, so the nurse should gently pull the pinna up and back to straighten the canal for optimal visualization of the tympanic membrane. This allows the otoscope to pass easily and prevents trauma or discomfort.

Choice B:

Down and forward: This method is used for infants and children under age 3, whose ear canals angle more downward and are shorter.

Choice C:

Away from the examiner: Pulling the ear "away" is vague and not clinically specific. It does not refer to the anatomical direction required to straighten the canal.

Choice D:

In any direction: This is unsafe and inaccurate. Improper manipulation can cause pain or injury and obstruct the view of the tympanic membrane.

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Total Questions : 4

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Practice Exercise 2

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