Physical Diagnosis I Exam 3 - Practice Exam Questions

Contraction of which eye structure controls the amount of light that reaches the retina?

a. Retina

b. Iris

c. Sclera

d. Lens

B

The iris is able to dilate and contract, allowing light to reach the retina. The retina is deep within the eye and does not control the amount of entering light. The sclera is not able to dilate and contract. The lens is merely a transparent disc that acts as a focus for the retina.

Contraction or relaxation of the ciliary body:

a. allows voluntary blinking.

b. changes lens thickness.

c. regulates peripheral vision.

d. sends light impulses to the brain.

B

The lens is circularly supported by a framework of fibers from the ciliary body; contraction or relaxation of this structure results in a change in the thickness of the lens, allowing for accommodation as needed.

The sensory network of the eye is the: a. cornea.

b. iris.

c. pupil.

d. retina.

D

The retina acts as the sensory network of the eye in that it sends electric impulses to the brain that are transformed from light. The cornea, iris, and pupil act together as an opening for light to pass through the lens.

Retinal hemorrhages in an infant require investigation for:

a. retinoblastoma.

b. retrolental fibroplasia.

c. pituitary tumor.

d. child abuse.

D

Beyond newborn age, any hemorrhages to the retina indicate infection, allergy, or trauma and should be further investigated.

An increased level of lysozyme in the tears will occur normally during which life stage?

a. Adolescence

b. Childhood

c. Infancy

d. Pregnancy

D

Because of rising hormone levels, an increased amount of lysozyme is present in tears during pregnancy. Tears are not affected by increased lysozyme at any other stage in life.

Tears flow over the cornea and drain via the lacrimal sac into the:

a. anterior fossa.

b. posterior pharynx.

c. nasal meatus.

d. thyroglossal duct.

C

Anatomically, the eye is closest to the nose, so tears drain from the lacrimal sac into the nasal lacrimal duct.

Mrs. Alden is a 29-year-old pregnant patient in her third trimester. She tells you that her vision has

been a little blurred, and she thinks she needs to get new contact lenses. You should advise her to:

a. get new lenses as soon as possible to avoid complications.

b. wait until several weeks after delivery to get new lenses.

c. go to the nearest emergency department for evaluation.

d. change her diet to include more yellow vegetables.

B

Because of the increased level of lysozyme in the tears during pregnancy, a blurred sensation may occur but will subside several weeks after pregnancy. The blurred vision is a normal occurrence during pregnancy. It is not an emergency, nor is it diet-dependent.

Which of the following is a relatively benign condition that may occur during pregnancy or labor?

a. Macular degeneration

b. Papilledema

c. Subconjunctival hemorrhage

d. Cupping of the optic disc

C

Because of falling intraocular pressure during late stages of pregnancy, subconjunctival hemorrhages may occur and resolve spontaneously. Macular degeneration and cupping of the optic disc occur in older adults. Papilledema is never a benign condition.

When does the lens usually become more rigid while the ciliary muscle of the iris becomes weaker?

a. At 25 years of age

b. Around 35 years of age

c. Around 45 years of age

d. After 65 years of age

C

Starting at around 45 years of age, the lens starts to change and become more rigid, and the ciliary muscle begins to weaken.

A condition that typically develops by the age of 45 years is: a. presbyopia.

b. hyperopia.

c. myopia.

d. astigmatism.

A

By 45 years of age, a condition known as presbyopia develops; presbyopia involves a weakening of accommodation. Hyperopia occurs in early infancy. Myopia and astigmatism can occur at any time.

Which of the following findings, when seen in the infant, is ominous?

a. Difficulty tracking objects with the eyes

b. Appearing to have better peripheral than central vision

c. Blinking when bright light is directed at the face

d. White pupils on photographs

D

The absence of a red reflex, determined by physical examination or the appearance of white pupils on a photograph, is indicative of retinoblastoma, a serious retinal tumor.

The Rosenbaum card is used to measure:

a. distance perception.

b. near vision.

c. peripheral distortion.

d. the ability to identify colors.

B

The Rosenbaum card is best used to measure nearsightedness because the patient holds the card at a comfortable distance and reads from the card. The Rosenbaum card is not used to measure distance perception because distance perception cannot be accurately measured with a card held close to the patient. Peripheral vision is assessed by an examiner with hand movements. Color identification can be measured with color cards.

When measuring visual acuity, you are assessing cranial nerve: a. I.

b. II.

c. IV.

d. VI.

B

Visual acuity is controlled by cranial nerve II. Cranial nerve I deals with the sense of smell. Cranial nerve IV deals with accommodation. Cranial nerve VI deals with lateral eye muscle movements.

Measurement of near vision should be done:

a. in each eye separately.

b. with the head at a 45-degree angle.

c. with the use of primary colors.

d. with the use of the Snellen chart.

A

Near vision is measured with the Rosenbaum card and should be tested in each eye separately, with the patient holding the card in front of her or him at about 35 cm.

Mr. C's visual acuity is 20/50. This means that he:

a. can see 50% of what the average person sees at 20 feet.

b. has perfect vision when tested at 50 feet.

c. can see 20% of the letters on the chart's 20/50 line.

d. can read letters while standing 20 feet from the chart that the average person could

read at 50 feet.

D

Visual acuity is measured as a fraction, in which the top number is the distance that the patient is standing from the chart; the bottom number is the distance that an average person can stand and still read the line.

Peripheral vision can be estimated by means of which test?

a. Confrontation

b. Pupillary reaction

c. Accommodation

d. Snellen E chart

A

The confrontation test measures peripheral vision. The examiner sits or stands across from the patient and asks the patient to close one eye while the examiner closes the opposite eye. The examiner then proceeds to wave the fingers while moving the extended arms from a lateral to a central position along both the temporal and the nasal fields. The pupillary reaction test is done to observe the pupil's response to light. The accommodation test deals with the pupils' reaction to light. The Snellen E chart is used to measure visual acuity.

The criterion for determining the adequacy of a patient's visual field is:

a. the ability to discriminate primary colors.

b. the ability to discriminate details.

c. correspondence with the visual field of the examiner.

d. distance vision equal to that of an average person.

C

The examiner compares his or her own peripheral vision to that of the patient while performing the confrontation test, so unless the examiner is aware of a problem with his or her own vision, the examiner could assume that the fields are full if they match.

Periorbital edema is:

a. a sign of abnormality.

b. expected with aging.

c. more common in males.

d. present in children.

A

A clinical finding of periorbital edema should always be regarded as an abnormal finding until ruled otherwise.

Xanthelasma may suggest that the patient has an abnormality of:

a. lipid metabolism.

b. cognitive function.

c. renal metabolism.

d. bone marrow function.

A

Small, odd-shaped, yellow-colored plaques around the eyes—called xanthelasma—are actually lipid deposits and are characteristic of a lipid metabolism problem.

Mrs. S. is a 69-year-old woman who presents for a physical examination. On inspection of her eyes, you note that the left upper eyelid droops, covering more of the iris than does the right. This is recorded as:

a. exophthalmos on the right.

b. ptosis on the left.

c. nystagmus on the left.

d. astigmatism on the right.

B

Ptosis is when one of the upper eyelids covers more of the iris than the other lid, possibly extending over the pupil.

Ptosis may be secondary to:

a. paresis of a branch of cranial nerve III.

b. hyperthyroidism.

c. psoriasis.

d. blepharitis.

A

Ptosis is caused by a congenital defect of the muscle around the eye controlled by cranial nerve III. Hyperthyroidism causes exophthalmos. Psoriasis is a skin condition. Blepharitis is inflammation of the eyelid.

What is the name of the condition in which the eyelid is turned away, or everted, from the globe? a. Ectropion

b. Entropion

c. Exophthalmos

d. Ptosis

A

Ectropion describes an everted lower lid that is turned away from the eye. Entropion describes the lower lid turning inward. Exophthalmos describes the bulging of the eye globe. Ptosis refers to a drooping of the upper eyelid.

Entropion implies that the lower eyelid is:

a. drooping.

b. everted.

c. edematous.

d. turned inward.

D

Entropion involves a slight inward turn of the lower eyelid.

A condition in which the eyelids do not completely meet to cover the globe is called: a. glaucoma.

b. lagophthalmos.

c. exophthalmos.

d. hordeolum.

B

Lagophthalmos is a term used to describe the condition in which eyelids do not completely meet when closing. Glaucoma involves elevated pressure in the eye. Exophthalmus involves bulging eyes. A hordeolum is better known as a stye.

Inspection of the tarsal conjunctiva should be performed:

a. with every eye examination.

b. in eye examinations in patients older than 45 years.

c. when a foreign body may be present.

d. for the patient with glaucoma.

C

Inspecting the tarsal conjunctiva involves pulling the top eyelid down and up while everting the lid. This maneuver is reserved for inspecting for the presence of a foreign body.

Mr. Morris is a 38-year-old patient who presents to the clinic with complaints of allergies. An allergy

can cause the conjunctiva to have a:

a. cobblestone pattern.

b. dry surface.

c. subconjunctival hemorrhage.

d. rust-colored pigment.

A

A red or cobblestone pattern, especially to the upper conjunctiva, indicates allergic conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or rust-colored pigment.

An abnormal growth of conjunctiva extending over the cornea from the limbus is known as:

a. a cataract.

b. erythematous.

c. glaucoma.

d. a pterygium.

D

An abnormal growth of the conjunctiva that extends over the cornea is called a pterygium. Cataracts and glaucoma do not affect the conjunctiva. Erythematous means that the area is red and irritated.

A pterygium is more common in people heavily exposed to:

a. high altitudes.

b. tuberculosis.

c. ultraviolet light.

d. cigarette smoke.

C

Persons heavily exposed to ultraviolet light are more susceptible to the development of a pterygium.

Mr. Brown was admitted from the emergency department, and you are completing his physical examination. His pupils are 2 mm bilaterally, and you notice that they fail to dilate when the penlight is moved away. This is characteristic in patients who are or have been:

a. in a coma.

b. taking sympathomimetic drugs (cocaine).

c. taking opioid drugs (morphine).

d. treated for head trauma.

C

Pupil constriction to less than 2 mm is called miosis. With miosis, the pupils fail to dilate in the dark, a common result of opioid ingestion or the use of drops for glaucoma. Pupils are usually dilated greater than 6 mm in a patient described in the other choices.

When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient to

respond by:

a. brisk blinking.

b. copious tearing.

c. pupil dilation.

d. reflex smiling.

A

Brisk blinking is an expected response to corneal sensitivity testing, which involves gently touching the cornea with a piece of cotton.

You observe pupillary response as the patient looks at a distant object and then at an object held 10 cm from the bridge of the nose. You are assessing for:

a. confrontation reaction.

b. accommodation.

c. pupillary light reflex.

d. nystagmus.

B

Testing for accommodation involves asking the patient to look at an object at a distance (pupils dilate) and then to look at another, much closer object (pupils constrict).

Mydriasis is an accompaniment of: a. coma.

b. diabetes.

c. hyperopia.

d. astigmatism.

A

Coma patients always have mydriasis, which occurs when the pupils are dilated more than 6 mm. Diabetes may cause a coma, but not mydriasis. Hyperopia is a condition of infants, describing their visual acuity as at or worse than 20/400. Astigmatism affects the shape of the lens, not the pupils.

The inequality of pupillary size is called: a. mydriasis.

b. diopter

c. ptosis.

d. anisocoria.

D

Anisocoria is when the pupil size is not the same but the reflexes remain normal. Mydriasis is when pupil size is large and even. Diopter is a unit of measurement used to focus a lens. Ptosis is a droopy eyelid.

When inspecting the region of the lacrimal gland, palpate:

a. the lower orbital rim, near the inner canthus.

b. in the area between the arch of the eyebrow and upper lid.

c. beneath the lower lid, adjacent to the inner canthus.

d. adjacent to the lateral aspect of the eye, just beneath the upper lid.

A

The lacrimal gland is located in the area between the arch of the eyebrow and upper lid. The lacrimal sac is located in the corner of the eye closest to the nose, near the inner canthus.

Examination to assess for extraocular muscle imbalance is conducted by:

a. comparing pupillary responses to different shapes.

b. having the patient follow your finger through planes.

c. inspecting slightly closed lids for fasciculations.

d. transilluminating the cornea with tangential light.

B

The test for extraocular muscle function is to have the patient follow an object as you move it through planes of vision while observing for nystagmus.

Mr. Older is a 40-year-old patient who presents to the office for a follow-up eye examination after

the diagnosis of myopia. To see retinal details in a myopic patient, you will need to:

a. adjust your ophthalmoscope into the plus lens.

b. move your ophthalmoscope backward.

c. move your hand farther forward.

d. turn your ophthalmoscope to a minus lens.

D

The myopic patient (nearsighted) has longer eyeballs, so that light rays focus in front of the retina. To see the retina, use the minus (red) numbers by moving the diopter wheel counterclockwise; to assess a hyperopic patient, use a plus lens.

The unit of measurement for describing lesion size and location on the fundus is the:

a. disc diameter.

b. macular diameter.

c. pupillary diameter.

d. centimeter.

A

When examining the eye and the fundus comes into focus, the branching of blood vessels becomes apparent. These always branch away from the optic disc and can be used as landmarks to locate the optic disc. The disc itself measures about 1.5 mm in diameter and is therefore the unit of measurement used to describe lesion size and location on the fundus.

Ask the patient to look directly at the light of the ophthalmoscope when you are ready to examine

the:

a. retina.

b. optic disc.

c. retinal vessels.

d. macula.

D

The macula is the site of central vision and is observed when the patient looks directly at the ophthalmoscope light.

Opacities of the red reflex may indicate the presence of: a. hypertension.

b. hydrocephalus.

c. cataracts.

d. myopia.

C

Opacities or dark spots of the red reflex may indicate the presence of congenital cataracts in the newborn.

If a patient has early papilledema, using an ophthalmoscope, the examiner will be able to detect:

a. dilated retinal veins.

b. retinal vein pulsations.

c. sharply defined optic discs.

d. visual defects.

A

Papilledema is caused by increased intracranial pressure along the optic nerve, pushing the vessels forward (cup protrudes forward) and dilating the retinal veins. Retinal vein pulsations and visual defects are not visible with an ophthalmoscope. On examination, papilledema is characterized by loss of definition of the optic disc.

Cupping of the optic disc may be a result of:

a. migraine headaches.

b. diabetes.

c. glaucoma.

d. dehydration

C

Cupping is seen with causes of increased intraocular pressure, such as glaucoma. Migraine headaches, diabetes, and dehydration do not cause cupping of the optic disc. Diabetes results in cotton wool patches and hemorrhages.

Drusen bodies are most commonly a consequence of: a. glaucoma.

b. aging.

c. presbyopia.

d. papilledema.

B

Drusen bodies, or lesions or spots on the retina, are part of the aging process.

When drusen bodies are noted to be increasing in number or in intensity of color, the patient should

be further evaluated with a(n):

a. Amsler grid.

b. Snellen E chart.

c. litmus test.

d. confrontation test.

A

Drusen bodies, when they increase in number or intensity of color, may indicate a precursor state of macular degeneration. When this happens, the patient's central vision should be assessed using the Amsler grid. The Snellen chart measures visual acuity, the litmus test is used for testing pH, and a confrontation test examines peripheral vision.

Cotton wool spots are most closely associated with:

a. glaucoma.

b. normal aging processes.

c. hypertension.

d. eye trauma.

C

Cotton wool spots actually represent infarcts of the retina and are associated with hypertension or diabetes.

The Keith-Wagner-Barker system group IV is characterized by the development of:

a. increased light reflex in the arterioles.

b. crossing defects.

c. cotton wool spots.

d. papilledema.

D

The Keith-Wagner-Barker system is used to classify changes to the eyes caused by hypertension. Group IV is the class that represents evidence of papilledema. An increased light reflex is in group I, crossing defects are in group II, and cotton wool spots are in group III.

Which of the following may be suggestive of Down syndrome?

a. Drusen bodies

b. Papilledema

c. Narrow palpebral fissures

d. Prominent epicanthal folds

D

Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome.

To differentiate between infants who have strabismus and those who have pseudostrabismus, use the: a. confrontation test.

b. corneal light reflex.

c. E chart.

d. Amsler grid.

B

The corneal light reflex is used with infants to differentiate between strabismus and pseudostrabismus by noting an asymmetric versus symmetric light reflex.

You are attempting to examine the eyes of a newborn. To facilitate eye opening, you would first:

a. dim the room lights.

b. elicit pain.

c. place him in the supine position.

d. shine the penlight in his or her eyes.

A

The best way to assess the eyes of a newborn is to start by dimming the lights because it encourages infants to open their eyes.

White specks scattered in a linear pattern around the entire circumference of the iris are called:

a. drusen bodies.

b. cotton wool spots.

c. rust spots.

d. Brushfield spots.

D

Brushfield spots are characterized by white specks that align perfectly around the circumference of the iris and strongly suggest Down syndrome or mental retardation.

Bone spicule pigmentation is a hallmark of:

a. chorioretinal pigmentosa.

b. cytomegalovirus infection.

c. lipemia retinalis.

d. retinitis pigmentosa.

D

Retinitis pigmentosa is inherited night blindness; it is characterized by the hallmark pigmentation of the peripheral fields or bone spicules. Chorioretinal pigmentosa and cytomegalovirus infection are not limited to night blindness, and lipemia retinalis is a result of an increase in triglyceride levels.

Horner syndrome is manifested by:

a. proptosis and contralateral mydriasis.

b. excessive watering of the eyes.

c. blurring of vision when glucose levels fall.

d. ipsilateral miosis and mild ptosis.

D

Horner syndrome is characterized by mild pupil constriction and drooping of the upper lid of the same eye. Horner syndrome is a result of a break in the sympathetic nerve supply to that eye. Mydriasis is manifested by enlarged pupils. Watering of the eyes and blurred vision are not affected by a disruption in the sympathetic nervous system.

Dot hemorrhages, or microaneurysms, in the retina and the presence of hard and soft exudates are

most commonly seen in those with:

a. Down syndrome.

b. diabetic retinopathy.

c. systemic lupus.

d. glaucoma.

B

Dot hemorrhages or tiny aneurysms are characteristic of background retinopathy. A trapping of lipids within incompetent capillaries causes the hemorrhages.

Which maneuver can be done to reduce the systemic absorption of cycloplegic and mydriatic agents

when examining a pregnant woman if the examination is mandatory?

a. Have the woman keep her eyes closed for several minutes.

b. Instill half the usual dosage.

c. Keep the patient supine, with her head turned and flexed.

d. Use nasolacrimal occlusion after instillation.

D

To reduce absorption systemically, the examiner may use nasolacrimal occlusion after applying, which involves pinching the upper bridge of the nose.

Episcleritis may indicate:

a. lipid abnormalities.

b. an autoimmune disorder.

c. an anaphylactoid reaction.

d. severe anemia.

B

Episcleritis is an inflammation of the sclera, involves purplish bumps, and is commonly associated with an autoimmune disorder.

Changes seen in proliferative diabetic retinopathy are the result of:

a. anoxic stimulation.

b. macular damage.

c. papilledema.

d. minute hemorrhages.

A

New vessels are a characteristic seen in proliferative retinopathy resulting from anoxic stimulation. An insufficient blood supply from failing capillaries causes new vessel growth.

Mrs. Jones brings her infant son in for a routine physical examination. She asks you, as the examiner, the age at which infants usually develop the ability to distinguish color. You explain that infants are first able to distinguish color at the age of ___ months.

6

By 6 months of age, vision has developed so that colors can be differentiated. At the age of 2 months, infants have not developed the ability to distinguish color. By the age of 12 months, infants already have the ability to distinguish color.

The most common cause of exophthalmos is _______________.

Graves Disease

Graves disease is the most common cause of exophthalmos, which is an increase in the eye tissue, resulting in the characteristic bulging eyes. However, if exophthalmos only involves one eye, the presence of a tumor should be suspected.

When there is an imbalance found with the corneal light test, you should then perform the ______________ test.

Cover-Uncover

If the corneal light reflex demonstrates an imbalance, the next test to perform is the cover-uncover test.

The Snellen E chart is appropriate for initial measurement of visual acuity in a child of age __ years.

3

For measurement of visual acuity with the Snellen chart to be accurate, the child must be cooperative; usually, by age 3 years, visual acuity can be assessed.

Term infants have a visual acuity of about____/_____.

20; 400

Term infants are hyperopic, with a visual acuity of less than 20/400.

Signs and symptoms or infant retinoblastoma include which of the following: (Select all that apply.)

a. White reflex

b. Red reflex

c. Corneal light reflex

d. Absence of a blink reflex

e. Autosomal dominant trait

f. Leukocoria

g. Visual acuity of 20/500

A, E, F

Retinoblastoma in an infant is marked by a characteristic white reflex, also called cat's eye reflex. Red reflex and corneal light reflex are expected findings. Absence of the blink reflex is not associated with retinoblastoma.