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°Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing(7th ed., p. 580). St. Louis: Mosby.°Cognitive Ability: Applying°Client Needs: Health Promotion and Maintenance°Integrated Process: Nursing Process/Assessment°Content Area: Health Assessment/Physical Exam
°Priority Concepts: Clinical Judgment, Sensory Perception°HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/PerceptionAwarded 1.0 points out of 1.0 possible points. °20.ID: 8482581697A nurse notes that a client's physical examination record statesthat the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? Normal near visionNormal central visionNormal peripheral visionNormal ocular movements Correct°Rationale: Leading the client’s eyes through the six cardinal fields of gaze will elicit any muscle weakness during movement. This test assesses the function of the medial rectusmuscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Near vision is tested with the use of a handheld vision screener that contains various sizes of print. Central vision is measured with the use of a Snellen chart. Peripheral vision is measured with the confrontation test.°Test-Taking Strategy: Recalling that the six cardinal fields of gaze are used to test for muscle weakness will direct you to the correct option. Also note the relationship of the words “moved” in the question and “movements” in the correct option. Review: this test .°Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care(6th ed., pp. 1078-1079). St. Louis: Saunders.°Cognitive Ability: Analyzing°Client Needs: Health Promotion and Maintenance°Integrated Process: Nursing Process/Assessment°Content Area: Adult Health/Eye °Priority Concepts: Clinical Judgment, Sensory Perception°HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sensory/PerceptionAwarded 1.0 points out of 1.0 possible points. °21.ID: 8482583513A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? PtosisNystagmus CorrectScleral icterusExophthalmos°Rationale: Nystagmus is a fine oscillating movement, most notable around the iris. The nurse checks for nystagmus when assessing a client for ocular muscle weakness. Mild nystagmus at extreme lateral gaze is normal; nystagmus at any other position is not. Ptosis is a drooping of the eyelid. Scleral icterus is a yellowing of the sclera, extending up to the cornea, that indicates jaundice. Exophthalmos, a noticeable protrusion of the eyeball, is a characteristic sign of hyperthyroidism.