nclex physical and health assessment questions

Correct Answer: C

Rationale: The correct answer is C because the nurse should use the Snellen chart positioned 6.1 m (20 ft) away to assess visual acuity. This is the standard method for testing distance vision. The nurse should ask the patient to read the letters on the chart from the top row down, covering one eye at a time if necessary. This method provides an accurate measurement of visual acuity at a distance. A: Performing the confrontation test assesses visual fields, not visual acuity. B: Using a Jaeger card is for near vision testing, not distance visual acuity. D: Assessing the ability to read newsprint at a close distance does not provide an accurate measurement of visual acuity at a distance.

Correct Answer: C

Rationale: Rationale: 1. The middle ear conducts sound vibrations from the outer ear to the inner ear via the ossicles. 2. This transmission is essential for the inner ear to convert the vibrations into electrical signals for the brain to interpret as sound. 3. Maintaining balance (A) is the function of the inner ear's vestibular system. 4. Interpreting sounds (B) is done by the brain, not the middle ear. 5. Increasing amplitude (D) would distort sound perception, not enable inner ear function.

Correct Answer: D

Rationale: The correct answer is D because intraocular pressure is primarily determined by the amount of aqueous humor produced and the resistance to its outflow at the angle of the anterior chamber. When there is an imbalance in the production and outflow of aqueous humor, it can lead to an increase in intraocular pressure, which can result in conditions like glaucoma. Choices A, B, and C are incorrect because they do not directly influence intraocular pressure. The thickness or bulging of the lens (A) is related to accommodation for near vision, the posterior chamber accommodating fluid (B) is not a primary factor in determining intraocular pressure, and the contraction of the ciliary body (C) affects the shape of the lens for focusing rather than intraocular pressure regulation.

Correct Answer: B

Rationale: The correct answer is B: shadow or diminished vision in one quadrant or one half of the visual field. Retinal detachment can cause a shadow or reduced vision specifically in one quadrant or one half of the visual field due to the detachment of the sensory retina from the underlying retinal pigment epithelium. This occurs because the detached retina disrupts the normal function of the photoreceptor cells leading to visual disturbances in that specific area. A: Loss of central vision is not a typical sign of retinal detachment, as it usually affects peripheral vision initially. C: Loss of peripheral vision can occur in retinal detachment, but it is not a defining characteristic as the detachment typically affects a specific quadrant or half of the visual field. D: Sudden loss of pupillary constriction and accommodation is not directly related to retinal detachment but may be seen in other eye conditions like acute angle-closure glaucoma.

Correct Answer: A

Rationale: The correct answer is A: An optic disc that is a yellow-orange colour. This is a normal finding because the optic disc typically appears yellow-orange due to the presence of nerve fibers. The yellow-orange color is due to the absence of blood vessels in this area. This is a normal anatomical characteristic of the optic disc. Option B is incorrect because blurred optic disc margins can indicate pathology such as papilledema. Option C is incorrect because the presence of pigmented crescents in the macular area can indicate a condition like myopic degeneration, not a normal finding. Option D is incorrect because the macula is normally located temporally, not nasally, to the optic disc.