Week 5 Review

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  PERRLA refers to:

• Motor Function

• Order of Assessment

• Level of Consciousness

• Pupillary Response

What all will the nurse assess when assessing the ears ?

Ear: external structure, alignment, position, drainage, tenderness 

• External structure

• Alignment & Position

• Hearing

• Drainage

• Tenderness

What is the term for involuntary shaking movement of the eyeball in a horizontal, vertical, rotary or mixed direction ?

• Nystagmus

• Myopia

• Hyperopia

• Starbismus

The nurse is performing an eye assessment on a client. Which finding confirms normal accommodation during visual assessment?

• Both pupils constrict when a light is shined at one eye.

• The client blinks in response to a threatening movement.

• Both pupils constrict when focusing on an object being moved in toward the nose.

• The client is able to hold an upward gaze without moving the head for 15 seconds.

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a:

• cluster headache

• migraine headache

• tension headache

• tumor-related headache

The nurse is preparing to examine an adult client’s eyes, using a Snellen chart. The nurse should:

• instruct the client to begin reading from the bottom of the chart

• position the client 20 feet away from the chart

• ask the client to remove his glasses

• ask the client to read each line with both eyes open

What nerve is purely sensory and transmits impulses for the sense of balance and transmits impulses for sense of hearing?

• Olfactory

• Optic

• Hypoglossal

• Vestibulocochlear

Moves eyes laterally away from the nose

• Abducens - VI

• Facial - VII

• Trigeminal - V

• Accessory - XI

Eye movement down and in

• Occulomotor - III

• Trochlear - IV

• Trigeminal - V

• Abducens - VI

Taste sensation on the anterior 2/3 of the tongue

• facial

• trigeminal

• glossopharyngeal

• hypoglossal