Chapter 15 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 15 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

The nurse is assessing a client who is 34 weeks pregnant. Which visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery?

Standard Text: Select all that apply.

1. The client is complaining that her eyes feel very dry.
2. She states that she is experiencing blurry vision.
3. Periorbital edema is noted.
4. Cataracts are noted.
5. She has been unable to wear her contact lenses.

Correct Answer: 1, 2, 5

Rationale 1: The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth.

Rationale 2: The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy.

Rationale 3: Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem.

Rationale 4: Cataracts are not commonly associated with pregnancy.

Rationale 5: Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort.

Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem. Cataracts are not commonly associated with pregnancy.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.1: Describe the anatomy and physiology of the eye.

MNL Learning Outcome: 5.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 295

 

Question 2

Type: MCSA

The nurse notes that a client is unable to control the amount of light that enters the eye. The dysfunction of which structure is the most likely cause of this problem?

1. Cornea.
2. Sclera.
3. Conjunctiva.
4. Iris.

Correct Answer: 4

Rationale 1: The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye.

Rationale 2: The sclera supports and protects the structures of the eye.

Rationale 3: The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry.

Rationale 4: The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye.

Global Rationale: The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye. The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye. The sclera supports and protects the structures of the eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.1: Describe the anatomy and physiology of the eye.

MNL Learning Outcome: 5.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 290

 

Question 3

Type: MCMA

The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. Which structures are involved in this process?

Standard Text: Select all that apply.

1. Lens.
2. Macula.
3. Cornea.
4. Iris.
5. Optic disc.

Correct Answer: 1, 3

Rationale 1: The lens is located directly behind the pupil and is used to refract light through the eye.

Rationale 2: The macula is located within the retina and does not assist with light refraction.

Rationale 3: The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction.

Rationale 4: The iris controls the amount of light that enters the eye, but is not associated with refraction.

Rationale 5: The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction.

Global Rationale: The lens is located directly behind the pupil and is used to refract light through the eye. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction. The macula is located within the retina and does not assist with light refraction. The iris controls the amount of light that enters the eye, but is not associated with refraction. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.1: Describe the anatomy and physiology of the eye.

MNL Learning Outcome: 5.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: pp. 290–291