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The nurse is collecting data and has just completed the Weber test on a patient with normal findings. How would the nurse correctly document the findings?
a.
Air conduction greater than bone conduction (BC).
b.
BC greater than A3.
c.
Left ear heard better than right ear.
d.
Left and right ear heard equally.
ANS: D
Normally a patient hears sound the same in both ears for a normal finding.
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The nurse performs a Snellen chart examination on a patient. What Snellen chart finding would indicate normal vision for the patient?
a.
Both eyes 20/20
b.
Left eye 20/200
c.
Left eye 80/20
d.
Right eye 200/20
ANS: A
Both eyes 20/20 is normal vision.
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The nurse has reinforced teaching with a patient after diagnostic testing reveals tinnitus. Which of the following patient statements indicates that teaching has been effective?
a.
“There is a toxic substance in my ear.”
b.
“That is why I have so much discharge all of the time.”
c.
“My ear pain should get better if I follow the doctor’s orders.”
d.
“The ringing sound I hear in my ear may be a symptom of another problem.”
ANS: D
Tinnitus is ringing, buzzing, or roaring in the ears. Discharge is otorrhea. Ear pain is otalgia.
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The nurse palpates a downward small protrusion of the helix known as Darwin’s tubercle. The nurse should document this as which of these?
a.
An abnormal palpable calcification
b.
Within normal limits
c.
A lump filled with fluid
d.
A tumor
ANS: B
A downward protrusion of the helix, called Darwin’s tubercle, is a normal finding.
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The nurse is providing initial screening to determine gross hearing acuity as part of a complete physical. Which of the following tests would the nurse include in the assessment?
a.
Romberg
b.
Whisper voice
c.
Otoscopic examination
d.
Calorie test
ANS: B
Auditory function can be grossly evaluated using three different assessment tests: whisper voice test, Rinne’s test, and Weber’s test.
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The nurse is collecting data for a patient who has hearing loss. Which data collection finding for the patient indicates this?
a.
Converses easily with the nurse
b.
Answers questions appropriately
c.
Relaxes facial features during conversation
d.
Speaks in an unusually loud voice
ANS: D
Speaking in an unusually quiet or loud voice can indicate hearing loss.
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The nurse is caring for a patient who asks what arcus senilis is. What is the nurse’s best explanation of arcus senilis?
a.
“An eye infection.”
b.
“A drooping of the eyelid.”
c.
“A mental condition.”
d.
“A lipid deposit in the cornea.”
ANS: D
In individuals older than 40 years of age, there may be bilateral opaque whitening of the outer rim of the cornea known as arcus senilus. It is caused from lipid deposits and is considered normal.
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The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which of the following should the nurse expect to be used?
a.
Ultrasonography
b.
An ophthalmoscope
c.
A slit-lamp microscope
d.
A tonometer
ANS: D
Estimation of intraocular pressure is measured by using one of several types of tonometer.
-
What anatomical ear structure functions to equalize pressure in the middle ear so that the eardrum can vibrate freely?
a.
Auricle
b.
Cochlea
c.
Eustachian tube
d.
Stapes
ANS: C
The eustachian tube extends from the middle ear to the nasopharynx and permits air to enter or leave the middle ear cavity.
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The nurse is caring for a patient who asks the nurse, “What part of the eye gives the eye its color?” What is the correct response by the nurse?
a.
Lens
b.
Iris
c.
Pupil
d.
Retina
ANS: B
The external eyes are inspected for color and symmetry of the irises.
-
Which of the following is the gelatin-like substance that gives shape to the eye and fills the space behind the lens?
a.
Vitreous humor
b.
Aqueous humor
c.
Lacrimal fluid
d.
Conjunctiva
ANS: A
The posterior cavity of the eye is between the lens and retina and contains vitreous humor. This semisolid substance helps keep the retina in place.
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The nurse is assisting with health screenings in a clinic. Which of the following would be considered a normal finding if noted lining the ear canal?
a.
Mucus
b.
Cerumen
c.
Perilymph
d.
Endolymph
ANS: B
The ear canal is lined with skin that contains ceruminous glands. Cerumen, or earwax, is the secretion that keeps the eardrum pliable and traps dust.
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The nurse is testing a patient’s peripheral visual ability. What technique would the nurse use?
a.
Visual fields
b.
Six cardinal fields of gaze
c.
Cover test
d.
Corneal light reflex test
ANS: A
Peripheral vision is tested by visual fields by confrontation.
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The nurse performs a visual assessment on a patient and is documenting the findings as the acronym PERRLA. What does PERRLA indicate?
a.
Palpebral angle rigid, right and left angles
b.
Patient’s eyes round, regular, lively, active
c.
Pupils equilateral, regular, round, little accommodation
d.
Pupils equal, round, and reactive to light and accommodation
ANS: D
PERRLA is pupils equal, round, and reactive to light and accommodation.
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The nurse is collecting data visually on a patient. Which of the following lighting environments will the nurse use to examine the patient’s pupils?
a.
Brightly lit room
b.
Slightly darkened room
c.
Natural lighting
d.
Completely darkened room
ANS: B
To test pupillary response to light, both consensual and direct examinations should be completed. A slightly darkened room works best.
-
The nurse is testing a patient’s visual muscle balance and movement. What technique could the nurse use to gather data on this?
a.
Visual fields
b.
Six cardinal fields of gaze
c.
Consensual pupillary reflex
d.
Direct pupillary reflex
ANS: B
The examiner moves his or her finger in the six cardinal fields of gaze, coming back to the point of origin between each field of gaze.
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The nurse is teaching a patient whose Snellen chart findings are 20/60. Which of the following statements would the nurse include in the patient teaching?
a.
“You are considered legally blind, even though with prescription glasses you’ll be able to see.”
b.
“Your vision is better than normal.”
c.
“You must be at 20 feet to see what normal vision sees at 60 feet.”
d.
“You must be at 60 feet to see what normal vision sees at 20 feet.”
ANS: C
Normal vision is 20/20, which means the patient can read at 20 feet what the normal eye can read at 20 feet. Visual impairment occurs at 20/70 and legal blindness at 20/200 or more with correction. For 20/60, the patient has less acute vision and must be at 20 feet to see what normal vision sees at 60 feet.
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The nurse administers eyedrops to a patient and instructs the patient to apply pressure to the inner corner of the eye for 1 minute after application of the drops. Which of these, if stated by a patient, indicates to the nurse correct understanding of the main purpose of why this pressure is applied?
a.
“To protect the facial skin from the eyedrops.”
b.
“To reduce absorption of eyedrops through tear duct.”
c.
“To increase the onset of action of the eyedrops.”
d.
“To maintain greater concentration of the eyedrops.”
ANS: B
Whenever eye medications, especially eyedrops, are administered, the punctum (tear duct) of the eye should have pressure applied to it for at least 1 minute. This reduces systemic absorption of the medication via the punctum.
-
The nurse is interviewing a patient. What behavior observed during the interview could indicate hearing loss?
a.
Patient cups the ear during interview.
b.
Patient leans away from the nurse during interview.
c.
Patient answers questions appropriately.
d.
Patient complains of people talking loudly.
- ANS: A
- Patient cups the ear during interview. Box 51-6 lists other behaviors.
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The nurse is contributing to the teaching for a high school health class regarding cerumen removal from the ear. Which of these instructions should the nurse recommend?
a.
“Cerumen protects the auditory canal; just use a washcloth to clean the external ear.”
b.
“Cerumen must be softened with Debrox before removal, and then an ear irrigation should be done.”
c.
“Wax is removed only when there is evidence of infection.”
d.
“Cerumen is removed regularly and thoroughly.”
ANS: A
The ear is generally self-cleaning. Wax is normally removed during showering. Wax serves as a protective mechanism to lubricate and trap foreign material.
-
The nurse is teaching a patient with a hearing disorder. Which of the following hearing losses would the nurse include are helped with a hearing aid?
a.
Central
b.
Conductive
c.
Congenital
d.
Sensorineural
ANS: B
Hearing aids are instruments that amplify sounds for conductive hearing loss. The use of a hearing aid can increase hearing for those who do not have nerve damage deafness.
-
The nurse is caring for a patient who is blind. What technique should the nurse use when ambulating the patient?
a.
Follow the patient with the patient’s hand on the nurse’s elbow.
b.
Precede the patient with the patient’s hand on the nurse’s elbow.
c.
Walk in front of the patient, telling the patient of any obstacles.
d.
Walk behind the patient with the nurse’s hand on the patient’s shoulder.
ANS: B
Precede the patient with the patient’s hand on the nurse’s elbow so that the nurse is leading the patient rather than pulling on the patient.
-
The nurse evaluates that a patient’s hearing aid is functioning properly when which of these occurs?
a.
It whistles constantly.
b.
The patient ignores verbal stimuli.
c.
It is properly placed in the ear.
d.
The patient converses easily.
ANS: D
The goal of the hearing aid is to facilitate conversation, so if this is occurring, then the hearing aid is functioning.
-
The nurse is caring for a patient who has presbycusis. What intervention would most enhance the nurse’s communication with the patient?
a.
Speaking in a low-pitched voice
b.
Speaking in a high-pitched voice
c.
Speaking in a very loud voice
d.
Speaking in a soft voice
ANS: A
Presbycusis is an age-related change in which progressive hearing loss is caused by loss of hair cells and decreased blood supply in the ear, resulting in a decreased ability to hear high-frequency sounds. Talking in a lower pitch helps with communication.
-
What structure changes the shape of the lens of the eye?
a.
Ciliary muscle
b.
Iris
c.
Retina
d.
Optic nerve
ANS: A
The ciliary body has a circular muscle that surrounds the edge of the lens and is connected to the lens by suspensory ligaments. The shape of the lens is changed by the ciliary muscle, which permits the focusing of light from objects at varying distances.
-
What are the receptors in the organ of Corti?
a.
Hair cells for hearing
b.
Ganglion cells for vibrations
c.
Hair cells for balance
d.
Ganglion cells for balance
ANS: A
The medial canal is the cochlear duct, which contains the receptors for hearing in the organ of Corti. The receptors are called hair cells, which contain endings of the cochlear branch of the eighth cranial nerve.
-
Which of the following is the cranial nerve for hearing?
a.
CN II
b.
CN IV
c.
CN VI
d.
CN VIII
ANS: D
When the hair cells in the ear bend, they generate impulses that are carried by the eighth cranial nerve to the brain for interpretation.
-
The nurse is assisting with a patient’s physical examination. For which of the following tests would the nurse anticipate the need to plan for patient safety?
a.
Weber’s test
b.
Whisper test
c.
Rinne’s test
d.
Romberg’s test
ANS: D
Romberg’s test, or falling test, is a simple test to assess vestibular function. If the patient has difficulty maintaining balance or loses balance, it can indicate an inner ear problem. If a fall appears likely, be prepared to support the patient to prevent injury.
-
The nurse is preparing a patient who will be having a digital retinal scan. Which of the following statements by the patient indicates further teaching is necessary?
a.
“My eyes will need to be dilated before the procedure.”
b.
“The scanner will take a picture in about 2 seconds.”
c.
“A digital image of most of my retina will be produced for the doctor to view.”
d.
“This test is used to help detect eye disease early.”
ANS: A
Digital imaging is a newer way of viewing the retina without requiring the use of dilating eyedrops. The instrument takes a digital picture of the retina in 2 seconds. The majority of the retina is viewable and assists in early detection of eye disease.
-
Which of the following are common age-related changes in vision and hearing? (Select all that apply.)
a.
Increased pupil size and response to light
b.
Decreased lacrimal secretions
c.
Loss of ability to hear low-frequency sounds
d.
Distorted depth perception
e.
Yellowing of the lens
f.
Presbycusis
ANS: B, D, E, F
To be true, A should be decreased pupil size and responsiveness to light, and C should be loss of ability to hear high-frequency sounds.
-
The nurse places eye drops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which of the following patient statements indicate that further instruction is needed? (Select all that apply.)
a.
“I can watch television without moving my eye too much.”
b.
“I can listen to music or an audiotaped book but should not read or watch TV.”
c.
“I should try to open my eyelid under the patch hourly while awake.”
d.
“I should exercise my patched eye four times daily.”
e.
“I should apply pressure to the tear duct of the eye every 5 minutes.”
f.
“When I change the patch, it should be taped securely enough to help the eyelid stay closed.”
ANS: A, C, D, E
A, C, D, and E should not be done, so the patient would need further instruction for understanding. B and F are correct and would indicate understanding.
-
The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which of the following tests identified by the patient would indicate a correct understanding of the teaching? (Select all that apply.)
a.
Electroretinography
b.
Corneal light reflex
c.
Fluorescein angiography
d.
Cover test
e.
Tonometer readings
f.
Computed tomography
ANS: B, D
The cover test is used in conjunction with an abnormal corneal light reflex test to evaluate muscle balance.
-
Legal blindness occurs at a Snellen chart rating of ____________________ with correction.
ANS:
20/200
Legal blindness occurs at a Snellen chart rating of 20/200 with correction.
-
When being tested for visual acuity, the patient should hold a handheld visual acuity chart approximately ____________________ inches from the eyes.
ANS:
14
When being tested for visual acuity, the patient should hold a handheld visual acuity chart approximately 14 inches from the eyes.
-
Noises reach a pain threshold at ____________________ dB.
ANS:
130
Noises reach a pain threshold at 130 dB.
-
The steps in giving eyedrop medications are listed. Place the steps in the order (1–6) they should be performed. All options must be used.
____ Instruct the patient to tilt head backward and look up toward the ceiling.
____ Check the medications for dosage, strength, side effects, contraindications, and expiration date.
____ Approach the patient’s eye from the side, and instill the prescribed amount of medication into the lower lid pocket.
____ Gently pull the lower lid down and out to form a pocket.
____ Gently apply pressure with a tissue to the punctum for at least 1 minute to prevent the medication from being absorbed systemically.
____ Wipe any excess medication from eyelids or cheek.
- ANS:
- ANS: 2
- ANS: 1
- ANS: 4
- ANS: 3
- ANS: 5
- ANS: 6
Check the medications for dosage, strength, side effects, contraindications, and expiration date; instruct the patient to tilt head backward and look up toward the ceiling; gently pull the lower lid down and out to form a pocket; approach the patient’s eye from the side, and instill the prescribed amount of medication into the lower lid pocket; gently apply pressure with a tissue to the punctum for at least 1 minute to prevent the medication from being absorbed systemically; and wipe any excess medication from eyelids or cheek
-
Place the following steps in order (1–6) as they occur during the process of hearing. All options must be used.
____ Sound waves strike the eardrum causing it to vibrate.
____ Vibrations pass through the cochlea.
____ The stapes transmits vibrations to the inner ear at the oval window.
____ Vibrations are transmitted through the auditory bones.
____ Vibrations pass through hair cells in the organ of Corti.F. ____ Impulses are carried by the eighth cranial nerve to the brain.
- ANS:
- ANS: 1
- ANS: 4
- ANS: 3
- ANS: 2
- ANS: 5
- ANS: 6
Sound waves strike the eardrum causing it to vibrate; vibrations are transmitted through the auditory bones; the stapes transmits vibrations to the inner ear at the oval window; vibrations pass through the cochlea; vibrations pass through hair cells in the organ of Corti; impulses are carried by the eighth cranial nerve to the brain.
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